Point Of Care Echocardiography Research Articles

Impact of Deliberate Practice on Point-of-Care Ultrasound Interpretation of Right Ventricle Pathology.

BackgroundPoint-of-care (POC) ultrasound (POCUS) has become an essential tool in caring for critically ill patients in several specialties. Mastery in POCUS requires competency in image acquisition, image interpretation, and integration into clinical care. Deliberate practice is an effective method for performance improvement in many areas of medical education; however, it is not well described in the literature for POCUS training.ObjectiveTo analyze differences in the effect of deliberate practice in POCUS image interpretation on performance improvement in groups with varying skill levels.MethodsWe recruited attending physicians and trainees with varying degrees of expertise in POCUS to complete a 50-item educational instrument on the interpretation of right ventricle size and function. The instrument incorporated deliberate practice for the task of correctly identifying right ventricle size and function as either normal or abnormal. Pulmonary critical care trainees obtained and interpreted POCUS images of patients with diagnosed acute pulmonary embolism, which were compared with gold-standard, two-dimensional echocardiographic scans obtained by an expert technician and interpreted by a cardiologist board-certified in echocardiography. We mapped learners’ cumulative accuracy on a learning curve to assess their performance. In addition, we compared groups on the basis of prior experience with using POC echocardiography.ResultsSeventy-nine of 81 participants completed the survey and examination and were included in the analysis. Of the participants, 69 (87.3%) were trainees. The overall cumulative accuracy for the group was 72.9%. All groups demonstrated improvement in accuracy with repetitive practice.ConclusionDeliberate practice in POC echocardiograph interpretation is effective for improving performance in a wide range of learners. Further study is needed to define accuracy cutoffs for competency to help guide learning plans and program requirements and for application into a model for global POC echocardiography competence.

Point of care echocardiography and lung ultrasound in critically ill patients with COVID-19.

Hundreds of millions got infected, and millions have died worldwide and still the number of cases is rising.Chest radiographs and computed tomography (CT) are useful for imaging the lung but their use in infectious diseases is limited due to hygiene and availability.Lung ultrasound has been shown to be useful in the context of the pandemic, providing clinicians with valuable insights and helping identify complications such as pleural effusion in heart failure or bacterial superinfections. Moreover, lung ultrasound is useful for identifying possible complications of procedures, in particular, pneumothorax.Associations between coronavirus disease 2019 (COVID-19) and cardiac complications, such as acute myocardial infarction and myocarditis, have been reported. As such, point of care echocardiography as well as a comprehensive approach in later stages of the disease provide important information for optimally diagnosing and treating complications of COVID-19.In our experience, lung ultrasound in combination with echocardiography, has a great impact on treatment decisions. In the acute state as well as in the follow-up setting after a severe or critical state of COVID-19, ultrasound can be of great impact to monitor the progression and regression of disease.Video onlineThe online version of this article contains 4 videos. The article and the videos are available online (10.1007/s00508-021-01968-y). The videos can be found in the article back matter as “Electronic Supplementary Material”.

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era.

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Left ventricle ejection fraction estimation by point of care echocardiography in patients admitted in intensive care unit

Background: Point of care ultrasonography (POCUS) by non-cardiologist is a safe and rapidly evolving diagnostic modality for the assessment of left ventricular ejection fraction (LVEF). This study aims to correlate the eyeball estimation of LVEF (EBEF) with modified Simpson’s method and linear measurement in M-mode parasternal long axis view (PLAX).
 Methods: A descriptive cross-sectional study was conducted at Chitwan Medical College. POCUS was performed in all ICU patients on the day of admission with optimal image acquisition and LVEF was estimated by three different methods and correlation of results were analyzed. 
 Results: Out of total 52 patients studied, median age was 58.38 ± 17.58 years (range: 24 – 89 years). There were 28 males (53.8%) and 24 females (46.2%) in this study. LVEF measured by eyeballing method and modified Simpson’s method had excellent correlation (Pearson’s correlation coefficient (r) = 0.956, P<0.001). However, there was only a good correlation (r= 0.882, P<0.001) between linear measurement method in M-mode view and Simpson’s method. It was found that eyeballing method underestimates EF as measured by Simpson’s method by an average of 2.33% (95% CI: 1.12 – 3.55%).Similarly, EF measurement by linear method overestimates EF as compared to results observed by Simpson’s method by an average of 6.57% (95% CI: 4.87 – 8.27%).
 Conclusions: Excellent correlation was observed between EBEF and modified Simpson’s method while linear measurements in M-mode may give incorrect estimation of EF especially in patients with regional wall motion abnormality.

Point-of-Care Echocardiography Unveils Misclassification of Acute Kidney Injury as Hepatorenal Syndrome

Introduction: Fulfillment of the diagnostic criteria for ­hepatorenal syndrome type 1 (HRS-1) requires prior failure of 2 days of intravenous volume expansion and/or diuretic withdrawal. However, no parameter of volume status is used to guide the need for volume expansion in patients with suspected HRS-1. We hypothesized that point-of-care echocardiography (POCE) may better characterize the volume status in patients with acute kidney injury (AKI) and cirrhosis to ascertain or disprove the diagnosis of HRS-1. Methods: A pilot observational study was conducted to determine the clinical utility of POCE-based examination of inferior vena cava diameter (IVCD) and collapsibility index (IVCCI) to assess intravascular volume status in patients with cirrhosis and AKI who had been deemed adequately volume-repleted and thereby assigned a clinical diagnosis of HRS-1. Early improvement in kidney function was defined as ≥20% decrease in serum creatinine (sCr) at 48–72 h. Results: A total of 53 patients were included. The mean sCr at the time of volume assessment was 3.2 ± 1.5 mg/dL, and the mean Model for End-Stage Liver Disease score was 29 ± 8. Fifteen (23%) patients had an IVCD <1.3 cm and IVCCI >40% and were reclassified as fluid-depleted, 11 (21%) had an IVCD >2 cm and IVCCI <40% and were reclassified as fluid-expanded, and 8 (15%) had and IVCD <1.3 cm and IVCCI <40% and were reclassified as having intra-abdominal hypertension (IAH). Twelve (23%) patients exhibited early improvement in kidney function following a POCE-guided therapeutic maneuver, that is, volume expansion, diuresis, or paracentesis for those deemed fluid-depleted, fluid-expanded or having IAH, respectively. Conclusion: POCE-based assessment of volume status in cirrhotic individuals with AKI reveals marked heterogeneity. Unguided volume expansion in these patients may lead to premature or delayed diagnosis of HRS-1.

Feasibility and diagnostic accuracy of point-of-care handheld echocardiography in acute ischemic stroke patients \u2013 a pilot study

BackgroundStandard echocardiography (SE) is an essential part of the routine diagnostic work-up after ischemic stroke (IS) and also serves for research purposes. However, access to SE is often limited. We aimed to assess feasibility and accuracy of point-of-care (POC) echocardiography in a stroke unit (SU) setting.MethodsIS patients were recruited on the SU of the University Hospital Würzburg, Germany. Two SU team members were trained in POC echocardiography for a three-month period to assess a set of predefined cardiac parameters including left ventricular ejection fraction (LVEF). Diagnostic agreement was assessed by comparing POC with SE executed by an expert sonographer, and intraclass correlation coefficient (ICC) or kappa (κ) with 95% confidence intervals (95% CI) were calculated.ResultsIn the 78 patients receiving both POC and SE agreement for cardiac parameters was good, with ICC varying from 0.82 (95% CI 0.71–0.89) to 0.93 (95% CI 0.87–0.96), and κ from 0.39 (−95% CI 0.14–0.92) to 0.79 (95% CI 0.67–0.91). Detection of systolic dysfunction with POC echocardiography compared to SE was very good, with an area under the curve of 0.99 (0.96–1.00). Interrater agreement for LVEF measured by POC echocardiography was good with κ 0.63 (95% CI 0.40–0.85).ConclusionsPOC echocardiography in a SU setting is feasible enabling reliable quantification of LVEF and preliminary assessment of selected cardiac parameters that might be used for research purposes. Its potential clinical utility in triaging stroke patients who should undergo or do not necessarily require SE needs to be investigated in larger prospective diagnostic studies.

Assessment of Left Ventricular Function in the Critically Ill Patient

A rapid qualitative assessment of left ventricular (LV) function is one of the cornerstones of point of care ultrasonography. The purpose of this review is to use a case-based approach to demonstrate how point of care echocardiography can be used to perform a qualitative assessment of LV systolic function. Various studies have demonstrated that using standard goal-directed echocardiography views, the assessment of myocardial thickening, endocardial excursion and the motion of the anterior leaflet of the mitral valve can be used to classify the LV systolic function into four broad categories: (1) normal, (2) hyperdynamic, (3) reduced, and (4) severely reduced LV function. Rapid qualitative assessment of LV systolic function provides valuable information, especially in patients with undifferentiated shock. However, it is important for the sonographer to recognize their limitations, be well versed in the pitfalls of each technique, and request a formal evaluation where appropriate.

Assessment of adequacy of volume resuscitation.

It has recently become evident that administration of intravenous fluids following initial resuscitation has a greater probability of producing tissue edema and hypoxemia than of increasing oxygen delivery. Therefore, it is essential to have a rational approach to assess the adequacy of volume resuscitation. Here we review passive leg raising (PLR) and respiratory variation in hemodynamics to assess fluid responsiveness. The use of ultrasound enhances the clinician's ability to detect and predict fluid responsiveness, whereas enthusiasm for this modality must be tempered by recent evidence that it is only reliable in apneic patients. The best predictor of fluid response for hypotensive patients not on vasopressors is a properly conducted passive leg raise maneuver. For more severely ill patients who are apneic, mechanically ventilated and on vasopressors, point of care echocardiography is the best choice. Increases in vena caval diameter induced by controlled positive pressure breaths are insensitive to arrhythmias and can be performed with relatively brief training. Most challenging are patients who are awake and on vasopressors; we suggest that the best method to discriminate fluid responders is PLR measuring changes in cardiac output.

Point of Care Echocardiography in an Acute Thoracic Dissection with Tamponade in a Young Man with Chest Pain, Tachycardia, and Fever

BackgroundAlthough thoracic aortic dissections are uncommon in young patients, they must be considered in the differential diagnosis in the presence of chest pain and abnormal vital signs. Although computed tomography angiography is the test of choice for thoracic dissection in the emergency department, point of care (POC) transthoracic echocardiography has a high specificity in the diagnosis of this disease. It is especially helpful in patients with proximal ascending dissections in the presence of a pericardial effusion. Case ReportThis case report illustrates a young patient presenting with chest pain, persistent tachycardia, and fever with a presumed upper respiratory infection who had an ascending thoracic dissection with tamponade discovered on POC echocardiography. Why Should An Emergency Physician Be Aware of This?POC echocardiography should be an important part of the algorithm in young patients presenting with chest pain and abnormal vital signs that do not improve with supportive measures. Definitive care in patients who present with a thoracic aortic dissection in the presence of cardiac tamponade diagnosed on POC echocardiography should not be delayed in order to wait for other imaging methods to be performed. POC echocardiography may expedite care and treatment in young patients presenting with this deadly disease.

Point of care echocardiography in the emergency room

Purpose: Apical hypertrophic cardiomyopathy (AHM) is a variant of hypertrophic cardiomyopathy, involving nearly exclusively apex. It is very common among Asian patients, predominantly in Japanese, which is considered relatively benign condition. However, severe clinical manifestations, including sudden cardiac death, severe arrhythmias and apical infarction have been described in case reports. The electrocardiographic changes (giant negative T waves) and associated symptoms (chest pain, palpitations, dyspnea...) often present as acute coronary sindromes. AHM diagnosis is based on the demonstration of myocardial hypertrophy in the apical region of the left ventricle, usually by echocardiography with classical image “ace of spades”, although in many cases the use of contrast necessary. We present a case of young patient admited at ER with palpitations. Material & Methods: The most frequent morbid events in Eriksson et al study of AHM were atrial fibrillation (AF), probably related to left atrial enlargement and impaired LV relaxation. It is prudent to also closely examine the heart on bedside emergency echocardiography looking for the presence of left atrial enlargement. Results: 37 year old male, with no significant medical history, was admitted to the ER by palpitations. The electrocardiogram showed AF with deep, negative T-waves in leads V3-V6. Bedside emergency echocardiography (BEE) initially performed to look for left atrial enlargement, revealed apical hypertrophy, with apical cavity obliteration during systole. These findings were confirmed by contrast ecocardiography. The patient was diagnosed with AHM (Yamaguchi's syndrome) and started on beta-blocker therapy. Conclusion: In this case, BEE helped to identify an AHM. It was the findings on emergency ultrasound, performed and interpreted by EPs, that helped to identify the correct diagnosis and prompted the appropriate consultations to cardiologist, with a final diagnostic of AHM.

Value of interactive scanning for improving the outcome of new-learners in transcontinental tele-echocardiography (VISION-in-Tele-Echo) study.

Point-of-care (POC) echocardiography may be helpful for mass triage, but such a strategy requires adequately trained sonographers at the remote site. The aim of this study was to test the feasibility of using a novel POC echocardiography training program for improving physicians' imaging skills during preanesthetic cardiac evaluations performed in a community camp organized for treating cataract blindness. Seventeen physicians were provided 6 hours of training in the use of POC echocardiography; nine were taught on site and eight were taught online through a transcontinental tele-echocardiography system. The trained physicians subsequently scanned elderly patients undergoing cataract surgery. The quality of images was graded, and agreement between local physicians' interpretations and Web-based interpretations by worldwide experts was compared. A total of 968 studies were performed, with 660 used for validating physicians' competence. Major cardiac abnormalities were seen in 136 patients (14.2%), with 32 (3.3%) deemed prohibitive to surgery in unmonitored settings. Although good-quality images were obtained more frequently by physicians trained on site rather than online (P = .03), there were no differences between the two groups in agreement with expert interpretations. The majority of physicians (70.6%) expressed satisfaction with the training (average Likert-type scale score, 4.24 of 5), with no difference seen between the two groups. The training resulted in significant improvements in self-perceived competence in all components of POC echocardiography (P < .001 for all). This study establishes the feasibility of using short-duration, one-on-one, personalized transcontinental tele-echocardiography education for wider dissemination of echocardiographic skills to local physicians in remote communities, essential for optimizing global cardiovascular health.

Hemodynamic Monitoring in the ICU

This review examines the most commonly used hemodynamic monitoring devices in the intensive care unit. After a brief review of some important issues in hemodynamic monitoring, a variety of monitoring systems are considered, including arterial catheters, pulmonary artery catheters (PACs), less invasive hemodynamic monitors, central venous oxygen saturation (ScvO2) monitors, and point-of-care (POC) echocardiography. For each system, the basic operating principles, indications and limitations of use, complications, key issues in data interpretation, and evidence regarding utility in patient care are reviewed. Figures depict the distinction between correlation and agreement, a representative Bland-Altman plot, a square wave test, PAC waveforms, principles of pulmonary artery occlusion pressure measurement, measuring pulmonary artery occlusion pressure at end-exhalation, right atrial and ventricular pressure waveform, pulmonary artery pressure waveform, potential pulmonary artery occlusion waveforms, west zones of the lung and the pulmonary artery occlusion pressure measurements, and POC echocardiography. Tables outline landmarks during insertion of the PAC from the internal jugular and subclavian vein insertion sites; indications, contraindications, and complications of PAC insertion; a comparison of less invasive hemodynamic monitors; reasons for decreased mixed or ScvO2; and indications and contraindications for transesophageal echocardiography. This review contains 12 highly rendered figures, 7 tables, and 95 references.

Ability of emergency physicians with advanced echocardiographic experience at a single center to identify complex echocardiographic abnormalities

ObjectivesTo determine the ability of emergency physicians to detect complex abnormalities on point-of-care (POC) echocardiograms. MethodsSingle-blinded, nonrandomized, cross-sectional study. Twenty-five different emergency medicine clinical scenarios (video clips and digital images) covering a variety of echocardiographic abnormalities were presented to a group of emergency physician sonologists. The echocardiographic abnormalities included right ventricular dysfunction, left ventricular systolic dysfunction, diastolic dysfunction, regional wall motion abnormalities, Doppler abnormalities of pericardial tamponade physiology, left ventricular hypertrophy, hypertrophic cardiomyopathy, and aortic abnormalities. All emergency physician sonologists were blinded to the study hypothesis. They reviewed echocardiography video clips and images individually, and their interpretations were compared with the criterion standard (expert echocardiographer interpretations). ResultsA total of 200 echocardiography studies (video clips and images) were independently reviewed by 8 emergency physician sonologists with varying POC echocardiography experiences. Emergency physicians accurately identified left ventricular systolic dysfunction 94% of the time, diastolic dysfunction (100%), and right ventricular dysfunction 80% of the time. Regional wall motion abnormalities were detected only 50% of the time. Doppler echocardiographic abnormalities of pericardial tamponade physiology were accurately identified 57% of the time. Emergency physicians who performed more than 250 POC echocardiograms were found to be more accurate in identifying complex echocardiographic abnormalities. ConclusionsOur study results suggest that with increased experience, emergency physicians can accurately identify most of complex echocardiographic abnormalities.

Point-of-Care Echocardiography by Pediatric Emergency Physicians

Currently, pediatric emergency medicine (PEM) physicians have limited data on point-of-care echocardiography (POCE). Our goals were to (1) determine the overall accuracy of POCE by PEMs in assessing left ventricular (LV) systolic function visually, presence or absence of pericardial effusion, and cardiac preload by estimating inferior vena cava (IVC) collapsibility, in acutely ill children in the pediatric emergency department; and (2) assess interobserver agreement between the PEM physician and pediatric cardiologist. This is a prospective, observational study conducted in an urban, tertiary pediatric facility with an annual census of 67,000 emergency department visits. Patients between the ages of 0 and 18 years meeting 1 or more of the following inclusion criteria were recruited: (1) cardiopulmonary arrest, (2) fluid refractory shock requiring vasoactive infusions, (3) undifferentiated cardiomegaly on chest radiography, and (4) receiving emergent formal echocardiography. All eligible patients underwent POCE by 1 of 2 trained PEM physicians. Dynamic video clips were recorded and reviewed by a pediatric cardiologist who was unaware of the clinical condition of the study patients. For a period of 18 months, we recruited 70 patients. Diminished LV function was noted in 17, pericardial effusion in 16, and abnormal IVC collapsibility in 35 patients. The κ statistics of agreement between the PEM and the cardiologist for detection of LV function, IVC collapsibility, and effusion were 0.87 (95% confidence interval [CI], 0.73-1.00), 0.73 (95% CI, 0.59-0.88), and 0.77 (95% CI, 0.58-0.95), respectively. The overall sensitivity and specificity of POCE compared with a formal echocardiogram was 95% (95% CI, 82%-99%) and 83% (95% CI, 64%-93%), respectively. With goal-directed training, PEM physicians may be able to perform POCE and accurately assess for significant LV systolic dysfunction, vascular filling, and the presence of pericardial effusion. The model may be expanded to train physicians to use POCE.

Physician-performed point-of-care echocardiography using a laptop platform compared with physical examination in the cardiovascular patient

OBJECTIVESThe purpose of this study was to compare the results of physical examinations (PEs) performed by board-certified cardiologists with the results of point-of-care (POC) echocardiography in a group of patients with cardiovascular disease.BACKGROUNDAlthough cardiovascular PE is crucial in the evaluation of patients with suspected heart disease, the skills required to diagnose abnormal cardiovascular findings have been declining. Echocardiography is a powerful noninvasive cardiovascular diagnostic tool; however, echocardiographic evaluation of patients is not performed at the time of patient encounter (POC echocardiography), beacuse current platforms are cumbersome and expensive for individual physician use. The development of miniaturized echocardiographic equipment has the potential to overcome some of these limitations.METHODSThirty-six subjects had a complete cardiovascular examination by four board-certified cardiologists. The physicians subsequently imaged each patient using a miniaturized echocardiographic platform. The yield of PE and POC echocardiography were compared using a complete echocardiographic study as the gold standard, performed on an upper-end platform.RESULTSCardiac examination failed to detect 59% of the overall cardiovascular findings. Physician-performed echocardiography with the prototype device missed 29% of the overall cardiovascular pathology. When considering only the major cardiovascular findings, the cardiologists’ PEs still failed to correctly detect 43%. Point-of-care echocardiography reduced this to 21% without significant interphysician variation.CONCLUSIONSPoint-of-care echocardiography using a miniaturized echocardiographic platform substantially improved the detection of important cardiovascular pathology compared with PE. Use of this device by a cardiovascular specialist with training in echocardiography as a routine adjunct to PE appears to be useful.