Transthoracic Echocardiography Views Research Articles

Exploring heart dissection techniques for enhancing anatomical education: a pilot study to replicate transthoracic echocardiography.

For novice learners, converting two-dimensional (2D) images of echocardiography to three-dimensional (3D) cardiac structures is deemed challenging. This study aimed to develop an accurate dissection method of the heart to reproduce the transthoracic echocardiographic views on cadavers and elucidate new educational methods in human anatomy dissection courses. A total of 18 hearts were used in this study. After reflecting the anterior thoracic wall inferiorly, the hearts were excised from embalmed cadavers. Thereafter, three landmarks were set on the heart for each plane of the incision, and the hearts were incised to observe the three different echocardiographic views, which include the apical four-chamber view (A4C), parasternal long axis (PLAX) view, and parasternal short axis (PSAX) view at the papillary muscle level. If all structures for observation during routine echocardiography are clearly observed in each view, a successful incision is considered. All procedures and incisions were performed by the medical students. After a successful incision, hearts were returned to the original position in the pericardial sac for further observation. The success rates of incision for each view were 83.3% (5/6 success cases), 83.3% (5/6 success cases), and 66.7% (4/6 success cases) in the A4C view, PLAX view, and PSAX view at the papillary muscle level, respectively. This dissection method could probably be employed to reproduce transthoracic echocardiographic views on cadaveric hearts, which is beneficial for novice learners for a deeper understanding of the anatomy.

Echocardiographic determination of right ventricular volumes and ejection fraction: Validation of a truncated cone and rhomboid pyramid formula.

Echocardiographic assessment of right ventricular (RV) measurements may be challenging. The aim of this study was to develop a formula for calculation of RV volumes and function based on measurements of linear dimensions by 2-dimensional (2D) transthoracic echocardiography (TTE) in comparison to cardiovascular magnetic resonance (CMR). 129 consecutive patients with standard TTE and RV analysis by CMR were included. A formula based on the geometric assumptions of a truncated cone minus a truncated rhomboid pyramid was developed for calculations of RV end-diastolic volume (EDV) and RV end-systolic volume (ESV) by using the basal diameter of the RV (Dd and Ds) and the baso-apical length (Ld and Ls) in apical 4-chamber TTE views: RV EDV = 1.21 * Dd2 * Ld, and RV ESV = 1.21 * Ds2 * Ls. Calculations of RV EDV (ΔRV EDV = 10.2±26.4 ml to CMR, r = 0.889), RV ESV (ΔRV ESV = 4.5±18.4 ml to CMR, r = 0.921) and RV EF (ΔRV EF = 0.5±4.0% to CMR, r = 0.905) with the cone-pyramid formula (CPF) highly agreed with CMR. Impaired RV function on CMR (n = 52) was identified with a trend to higher accuracy by CPF than by conventional echocardiographic parameters (tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC)). Calculations of RV volumes and RV function by 2D TTE with the newly developed CPF were in high concordance to measurements by CMR. Accuracy for detection of patients with reduced RV function were higher by the proposed 2D TTE CPF method than by conventional echocardiographic parameters of TAPSE and RV FAC.

Prevalence and clinical correlates of ascending aortic dilatation in patients with noncompaction cardiomyopathy

Ascending aortic (AoAsc) dilatation can lead to acute aortic syndromes and has been described in various familial cardiac diseases. Its prevalence and clinical significance in patients with noncompaction cardiomyopathy (NCCM) are however unknown. Establishing the prevalence can facilitate recommendations on routine screening in NCCM. In this cross-sectional cohort study based on the Rijnmond Heart Failure/Cardiomyopathy Registry, the patient were enrolment between 2014 and 2021. All NCCM patients (n = 109) were age and sex matched with 109 dilated cardiomyopathy (DCM) patients as controls. The aortic diameters were measured through the parasternal long-axis transthoracic echocardiographic view at the sinuses of valsalva (SoV-Ao), sinotubular junction (STJ) and ascending aorta (AscAo). Dilatation was defined using published criteria adjusted for body surface area (BSA), sex, and age. Median age of age-sex matched NCCM and DCM patients was 45[31–56] vs. 45 [31–55] years with 53% males in both groups. NCCM patients had more familial hereditary patterns and genetic variants (55% vs. 24%, p < 0.001). DCM patients had more heart failure and left ventricular dysfunction (ejection fraction 34 ± 11 vs. 41 ± 12, p = 0.001). Ascending aortic dilatation was present in 8(7%) patients with NCCM and 5(5%) patients with DCM (p = 0.46). All dilatations were classified as mild. In conclusion, in this cross-sectional cohort study the prevalence of ascending aortic dilatation in NCCM patients was 7%, which were only mild dilatations and not significantly different from an age-sex matched cohort of DCM patients. Routine aortic dilatation screening therefore does not seem warranted in patients with NCCM.

Left Ventricular Outflow Obstruction in D-Transposition of Great Arteries: A Rare Etiology

A 2-day old neonate [gender: male; weight: 3.2 kg; height: 53cm] presented to the authors institution with an arterial oxygen saturation of 74%. The child was receiving 6 cm H2O continuous positive airway pressure therapy [FIO2: 0.5] and was treated with a prostaglandin E1 infusion [10ng/kg/min]. Transthoracic echocardiography revealed situs solitus, levocardia, normal systemic and pulmonary venous drainage and a 6 mm non-restrictive atrial septal defect with a left to right shunt. The atrioventricular connections were concordant. The aorta was arising from the right ventricle with no right ventricular outflow obstruction [Figure 1]. The pulmonary artery was arising from the left ventricle with confluent good size branch pulmonary arteries with posterior deviation of the conal septum [Figure 2]. A large perimembranous (conoventricular type)1 ventricular septal defect with an inlet [6 mm] and outlet [6 mm] extension and an additional tiny apical defect were demonstrated [Figure 3]. A patent ductus arteriosus [2.7 mm] shunting left to right was also present (not shown). A 2-dimensional echocardiography image in the parasternal long axis view displayed an obstruction to the left ventricular outflow tract [white arrow] and a color Doppler blood flow map demonstrated turbulence in the outflow tract [Figure 4A,B]. In the subcostal view with the probe tilted anteriorly, color flow Doppler mapping showed the ventricular septal defect and also the blood flow acceleration across the left ventricular outflow tract [Figure 5, videolip-1]. At the area of turbulence, the jet width was 0.234 cm[Figure 6A]. A continuous wave Doppler interrogation of the area demonstrated a gradient of ≈ 25 mmHg [Figure 6B]. 2-dimensional transthoracic echocardiography interrogation in the subcostal view identified the etiology of the left ventricular outflow tract obstruction [Figure 7, Videoclip-2]. What is the diagnosis? Figure 2Transthoracic echocardiography image showing the relationship between the pulmonary artery and the left ventricle. View Large Image Figure Viewer Download Hi-res image Figure 3Subcostal 4-chamber transthoracic echocardiography image showing the perimembranous ventricular septal defect. View Large Image Figure Viewer Download Hi-res image Figure 4A&B. Parasternal long axis transthoracic echocardiography 2-dimensional image showing the obstruction in the left ventricular outflow tract ‘white arrow’ [A], and turbulence in the outflow tract by a color Doppler blood flow map ‘white arrow’[B]. View Large Image Figure Viewer Download Hi-res image Figure 5Subcostal transthoracic echocardiography image showing color Doppler flow acceleration over the left ventricular outflow tract and a ventricular septal defect. View Large Image Figure Viewer Download Hi-res image Figure 6A&B. Subcostal transthoracic echocardiography image showing the width of the obstruction [A] and the pressure gradient across the obstruction [B]. View Large Image Figure Viewer Download Hi-res image Figure 7A subcostal transthoracic echocardiography view showing the etiology of the left ventricular outflow tract obstruction in systole. View Large Image Figure Viewer Download Hi-res image

Developing an Echocardiography-Based, Automatic Deep Learning Framework for the Differentiation of Increased Left Ventricular Wall Thickness Etiologies

Increased left ventricular (LV) wall thickness is frequently encountered in transthoracic echocardiography (TTE). While accurate and early diagnosis is clinically important, given the differences in available therapeutic options and prognosis, an extensive workup is often required to establish the diagnosis. We propose the first echo-based, automated deep learning model with a fusion architecture to facilitate the evaluation and diagnosis of increased left ventricular (LV) wall thickness. Patients with an established diagnosis of increased LV wall thickness (hypertrophic cardiomyopathy (HCM), cardiac amyloidosis (CA), and hypertensive heart disease (HTN)/others) between 1/2015 and 11/2019 at Mayo Clinic Arizona were identified. The cohort was divided into 80%/10%/10% for training, validation, and testing sets, respectively. Six baseline TTE views were used to optimize a pre-trained InceptionResnetV2 model. Each model output was used to train a meta-learner under a fusion architecture. Model performance was assessed by multiclass area under the receiver operating characteristic curve (AUROC). A total of 586 patients were used for the final analysis (194 HCM, 201 CA, and 191 HTN/others). The mean age was 55.0 years, and 57.8% were male. Among the individual view-dependent models, the apical 4-chamber model had the best performance (AUROC: HCM: 0.94, CA: 0.73, and HTN/other: 0.87). The final fusion model outperformed all the view-dependent models (AUROC: HCM: 0.93, CA: 0.90, and HTN/other: 0.92). The echo-based InceptionResnetV2 fusion model can accurately classify the main etiologies of increased LV wall thickness and can facilitate the process of diagnosis and workup.

Minimalist transcatheter aortic valve replacement misses paravalvular regurgitation:Incidence and echocardiographic distribution of missed paravalvular regurgitation.

Paravalvular regurgitation (PVR) may be missed intraoperatively with transthoracic echocardiography (TTE) guided minimalist TAVR. We sought to determine the incidence and echocardiographic distribution of PVR missed on intra-op TTE, but detected on predischarge TTE. From July 2015 to 2020, 475 patients with symptomatic severe native aortic stenosis underwent TTE-guided minimalist TAVR. Missed PVR was defined as predischarge PVR that was ≥1 grade higher than the corresponding intra-op PVR severity. PVR was classified as anterior or posterior on the four standard TTE views; parasternal short-axis (PSAX), parasternal long-axis (PLAX), apical 3-chamber (A3C), and 5-chamber (A5C). Location-specific risk of missed PVR was then determined. Mild or greater PVR was seen in 55 (11.5%) cases intra-op and 91 (19.1%) at predischarge, with no severe PVR. Among the 91 patients with ≥mild predischarge PVR, missed PVR was present in 42 (46.2%). Compared to the corresponding anterior jets, missed PVR rate was significantly higher for posterior jets in PLAX (62.5% vs. 25.0%, p = 0.005), A5C (56.9% vs. 25.0%, p = 0.009), PSAX (66.7% vs. 24.3%, 0.001), but not A3C (58.5% vs. 40.0%, p = 0.28). Intraoperative TTE-guided minimalist TAVR either misses nearly half of ≥mild PVR or underestimates PVR by ≥1 grade when compared to predischarge TTE. Posterior PVR jets are more likely to be missed. Transesophageal echo guidance may help minimize missing PVR. Further studies are warranted.

Comparison of the Quality of Echocardiography Imaging Between the Left Lateral Decubitus and Supine Positions.

Introduction It is commonly taught that positioning the patient in the left lateral decubitus (LLD) position will improve transthoracic echocardiography (TTE) image quality. Despite this, no previous studies have been performed that study this practice. Our goal was to quantify the difference in image quality of TTE views between the supine and LLD positions. Methods This was a prospective study in a single academic Emergency Department (ED) of a convenience sample of 30 patients. Three separate ED physicians performed TTE views in both the supine and LLD position on each patient. The order of position was randomized. Images were then reviewed on a previously validated TTE image quality scale by two blinded ED physicians with specialized training in ultrasound. The scale used a 0 to 5 (highest quality) metric for quality assessment. Interpretability of right ventricular and left ventricular function was also assessed. Results The mean image quality for the supine position was 2.85 (standard deviation {SD} 1.1) and 3.05 (SD 1.2) for the LLD position (p=0.044). In the subset of parasternal and apical windows, the mean quality for the supine position was 2.87 (SD 1.1) and 3.23 (SD 1.1) for the LLD position (p=0.003). The number of studies in which right ventricular function was interpretable was significantly higher in the LLD position (62% versus 42%, p=0.044). Conclusions There was a statistically significant increase in image quality when TTE was performed in the LLD position as compared to supine. This was especially pronounced in the apical four and parasternal windows.

The impact of 3D printed models on spatial orientation in echocardiography teaching

PurposeDuring our transthoracic echocardiography (TTE) courses, medical students showed difficulty in spatial orientation. We implemented the use of 3D printed cardiac models of standard TTE views PLAX, PSAX, and A4C and assessed their efficacy in TTE-teaching.MethodsOne hundred fifty-three participants were split into two groups. A pre-test-retest of anatomy, 2D -, and 3D orientation was conducted. The intervention group (n = 77) was taught using 3D models; the control group (n = 76) without. Both were comparable with respect to baseline parameters. Besides test-scores, a Likert scale recorded experiences, difficulties, and evaluation of teaching instruments.ResultsFrom the 153 students evaluated, 123 improved, 20 did worse, and ten achieved the same result after the course. The median overall pre-test score was 29 of 41 points, and the retest score was 35 (p < 0.001). However, the intervention group taught with the 3D models, scored significantly better overall (p = 0.016), and in 2D-thinking (p = 0.002) and visual thinking (p = 0.006) subtests. A backward multivariate linear regression model revealed that the 3D models are a strong individual predictor of an excellent visual thinking score. In addition, our study showed that students with difficulty in visual thinking benefited considerably from the 3D models.ConclusionStudents taught using the 3D models significantly improved when compared with conventional teaching. Students regarded the provided models as most helpful in their learning process. We advocate the implementation of 3D-printed heart models featuring the standard views for teaching echocardiography. These findings may be transferable to other evidence based medical and surgical teaching interventions.

Characteristics and potential hemodynamic benefits of proning on the right ventricle in intensive care patients with SARS-CoV-2 ARDS

Abstract Funding Acknowledgements Type of funding sources: None. Introduction One of the key challenges in treating COVID-19 ARDS patients is hemodynamic monitoring. Therapies proven to be effective in ARDS, such as protective ventilation, fluid restriction or high PEEP tend to alter right ventricular (RV) function and indicate a closer in-bed management, which is particularly difficult in prone position (PP) patients. Transthoracic echocardiography(TTE) enables a direct window for hemodynamic monitoring of RV performance. Objective To assess characteristics and potential hemodynamic benefits of proning on the RV in ICU patients with SARS-CoV-2 ARDS, using echocardiography. Methods This is an observational, cross-sectional study of SARS-CoV-2 ARDS in 11 patients hospitalized in a 12 bed ICU in Farhat Hached University hospital in December 2020. All patients were deeply sedated and curarized during the study. After a stabilization period (MAP ≥ 65mmHg), TTE was performed first in the supine position before putting the patient on PP. Same measures were repeated during a second scan 4 to 8 hours after PP setting. Norepinephrine infusion levels were not changed between the two scans. The average duration of a scan was 20 ± 10 minutes depending mostly on echogenicity. Several frequencies and harmonics were tested and we selected the ones that provided the best image quality. PP ventilation (PPV) was performed continuously for 12 hours using the "swimmer position" that enabled affordable TTE views. A quantitative study of the RV was performed using RV focused 4C view. A special view dedicated to the IVC was studied. Parameters measured were RV basal end diastolic diameter, S’ peak wave in TDI, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC) and maximal trans tricuspid velocity (MTTV). Post hoc analysis was performed by two readers (one intensivist and one cardiologist). All parameters are expressed as a mean of two measurements. Results Twenty-four TTEs were performed in 11 patients respectively 40 ± 15mn before and 5.8 ± 1.1hrs after the PP setting. Patients were 71.0 ± 9.4yrs aged, 5(45%) obese, 7(63%) had diabetes mellitus, 4(36%) hypertension, 1(9%) coronary artery disease. All (100%) were on sinus rhythm. 7(63.6%) presented moderate ARDS and 3(27.3%) severe ARDS. None of the patients developed RV failure prior to the examination. The PPV achieved a non-statistically significant improvement in RV function as assessed by the increase of S′, TAPSE, a decrease in RV basal diameter and an increase in FAC. A statistically significant decrease in MTTV (mean 3.20 ± 0.49 m/s before PP vs mean 2.47 ± 0.77m/s (p = 0.01)) was objectified. Conclusions PPV improves hemodynamic parameters of the RV. TEE 4C view is sufficient in the assessment of RV function in PP. SPAP monitoring could be the key parameter to quickly and reliably assess RV response to PPV.

The effectiveness of a blended POCUS curriculum on achieving basic focused bedside transthoracic echocardiography (TTE) proficiency. A formalized pilot study

ObjectiveThe study objective is to evaluate the effeteness of an existing educational platform blending didactic presentation and hands-on simulation for university doctoral SRNAs in the area of basic, 4 view identification and performance of transthoracic echocardiography (TTE).MethodsFollowing IRB approval, SRNAs were exposed to a pre test to evaluate existing skills, then they were exposed to a graphic rich, live presentation of basic 4 view TTE. The presentation was then followed by hands on simulation and performance of the 4 basic TTE views on live models.ResultsPretest scores averaged 58% and post tests scores rose to 95%. See Table 1.ConclusionOur results support the concept that the existing blended platform is effective to train university SRNAs in basic 4 view, bedside transthoracic echocardiography.

Transthoracic Echocardiography: Beginner's Guide with Emphasis on Blind Spots as Identified with CT and MRI.

Transthoracic echocardiography (TTE) is the primary initial imaging modality in cardiac imaging. Advantages include portability, safety, availability, and ability to assess the morphology and physiology of the heart in a noninvasive manner. Because of this, many patients who undergo advanced imaging with CT or MRI will have undergone prior TTE, particularly when cardiac CT angiography or cardiac MRI is performed. In the modern era, the increasing interconnectivity of picture archiving and communication systems (PACS) has made these images more available for comparison. Therefore, radiologists who interpret chest imaging studies should have a basic understanding of TTE, including its strengths and limitations, to make accurate comparisons and assist in rendering a diagnosis or avoiding a misdiagnosis. The authors present the standard TTE views along with multiplanar reformatted CT images for correlation. This is followed by examples of limitations of TTE, focusing on potential blind spots, which have been placed in seven categories on the basis of the structures involved: (a) pericardium (thickening, calcification, effusions, cysts, masses), (b) aorta (dissection, intramural hematoma, penetrating atherosclerotic ulcer), (c) left ventricular apex (infarcts, aneurysms, thrombus, apical hypertrophic cardiomyopathy), (d) cardiac valves (complications of native and prosthetic valves), (e) left atrial appendage (thrombus), (f) coronary arteries (origins, calcifications, fistulas, aneurysms), and (g) extracardiac structures (primary and metastatic masses). Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article . ©RSNA, 2021.

Automated evaluation of the right-sided heart function and geometry using deep learning

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Deep learning (DL) has been successfully applied in the automated assessment of some transthoracic echocardiography (TTE) parameters such as left-ventricular ejection fraction. Nevertheless, automation of the right-sided heart assessment has not been widely studied, partially due to the relative difficulty involved in some of the right-sided heart measurement evaluation and time constraints in routine practice. Here we have explored the feasibility of a DL-based system capable of performing different tasks involved in the right-sided heart functional and geometric evaluation. PURPOSE To develop a DL-based system assessing right atrium (RA) and right ventricle (RV) functional and geometric parameters and compare its accuracy to board-certified cardiologists. METHODS A total of 2,014 frames from 349 patients (with various indications for TTE) were used to train and validate four convolutional neural networks (CNNs) to perform either segmentation or landmark detection across four different TTE views: apical four-chamber (A4Ch), parasternal long-axis (PLAX), M-mode of tricuspid annulus and tissue Doppler imaging (TDI) of the right ventricular lateral wall. The CNNs were optimised to perform different right-sided heart measurements, namely, right atrial area in end-systole (RAA) and fractional area change (FAC) of RV in A4Ch view, proximal right ventricular outflow tract diameter (pRVOT) in PLAX view, tricuspid annular plane systolic excursion (TAPSE) in M-mode and S’ in TDI. Model performance was compared with two board-certified cardiologists using their average measurements on 20 test set patients. RESULTS CNN predicted pRVOT diameter with a mean absolute error (MAE) of 1.02 mm and root mean squared error (RMSE) of 3.08 mm. The intersection over union (IoU) for the segmentation of RV and RA was 0.89 and 0.87, respectively. We then used RV and RA segmentation predictions to calculate additional parameters which resulted in RMSE of 8.34% for FAC and 4.93cm2 for RAA. In the M-mode and TDI, the model achieved RMSE of 4.48 mm and 0.84 cm/s for the detection of TAPSE and S’, respectively. CONCLUSIONS We have demonstrated the feasibility of a DL-based system performing different measurements involved in right-sided heart evaluation. In a routine practice, where limited time resources might be available, such could assist in the thorough assessment of the right-sided heart geometry and function. Additional studies using cardiac magnetic resonance imaging to establish more precise accuracy of such systems is needed.

Point-of-Care Ultrasound Before and After Transfemoral Transcatheter Aortic Valve Implantation.

ObjectiveSurgical aortic valve replacement requires a comprehensive transoesophageal echocardiography (TEE) assessment before and after the intervention by cardiac anaesthesiologists. For patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI), TEE is not routinely used. We started using transthoracic echocardiography (TTE) as a diagnostic and monitoring modality during TF-TAVI procedures. The aim of this study is to examine the usefulness of TTE before and after TF-TAVI. We hypothesised that TTE can serve as a screening tool in TF-TAVI patients and help rule out significant paravalvular leaks (PVLs), and serve as a monitoring tool.MethodsA retrospective, observational study of 24 patients who underwent TF-TAVI with perioperative TTE over a 3-month period was conducted. Intraoperatively, two TTE examinations were performed. The first was a baseline pre-procedural TTE examination after anaesthetic induction, and the second was performed after TAVI valve implantation. Both pre- and post-procedural examinations included five focused TTE views. PVLs were graded as none, non-significant (trace or mild) or significant (moderate or severe).ResultsThe average age and median body mass index of the patients were 82 years and 28.5 kg m−2, respectively. The average time recorded for the pre- and post-TAVI TTE examinations were approximately 4 and 5.5 min, respectively. Non-significant PVL was detected in 6 (25%) patients, and no leak was detected in 18 (75%) patients.ConclusionA focused TTE examination was found to be a useful adjunct during TF-TAVI for a cardiac anaesthesiologist in the absence of TEE, and useful in ruling out significant PVLs.

Artificial intelligence-guided image acquisition on patients with implanted electrophysiological devices: results from a pivotal prospective multi-center clinical trial

Abstract Background A novel, recently FDA-authorized software uses deep learning (DL) to provide prescriptive transthoracic echocardiography (TTE) guidance, allowing novices to acquire standard TTE views. The DL model was trained by &amp;gt;5,000,000 observations of the impact of probe motion on image orientation/quality. This study evaluated whether novice-acquired TTE images guided by this software were of diagnostic quality in patients with and without implanted electrophysiological (EP) devices, focusing on RV size and function, which were thought to be sensitive to EP devices. Some aspects of the study have previously been presented. Methods 240 patients (61±16 years old, 58% male, 33% BMI &amp;gt;30 kg/m2, 91% with cardiac pathology) were recruited. 8 nurses without echo experience each acquired 10 view TTEs in 30 patients guided by the software. 235 of the patients were also scanned by a trained sonographer without assistance from the software. 5 Level 3 echocardiographers independently assessed the diagnostic quality of the TTEs acquired by the nurses and sonographers to evaluate the effect of EP devices on DL software performance. Results Nurses using the AI-guided acquisition software acquired TTEs of sufficient quality to make qualitative assessments of right ventricular (RV) size and function in greater than 80% of cases for patients with and without implanted EP devices (Table). There was no significant difference between nurse- and sonographer-acquired scans. Conclusion These results indicate that new DL software can guide novices to obtain TTEs that enable qualitative assessment of RV size even in the presence of implanted EP devices. The results of the comparison to sonographer-acquired exams indicate the software performance is robust to presence of pacemaker/ICD leads visible in the images (Figure). Nurse-acquired TTE with visible ICD lead Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Caption Health, Inc.

Optimization of Echo Views for Percutaneous Device Closure of Pediatric Atrial Septal Defect through the Femoral Vein Guided by Transthoracic Echocardiography without Radiation.

Objectives This study aimed to explore the selection of views for transthoracic echocardiography-guided transfemoral puncture for the device closure of pediatric atrial septal defect (ASD) without radiation. Methods Sixty children (29 males and 31 females) were diagnosed with a central ASD, normal heart function, and no other intracardiac deformity. All procedures were performed in a surgical operating room (without radiological equipment) under basic anesthesia; the femoral vein pathway and guidance by only transthoracic echocardiography were used to complete the device closure of the ASD. The subcostal acoustic window and parasternal aorta short-axis views were used to guide the extra stiff wire and catheter into the left atrium. All procedures were performed under the subcostal biatrial section. The sheath entered the left atrium, and the apical four-chamber view was used to monitor the delivery and release of the occluder. Results Successful closure of the ASD was achieved in all cases. The operating time from the end of the puncture to the release of the occluder was 10.36 ± 3.57 minutes. No other incisions were needed in 60 cases. No occluders were removed, and no residual shunt or pericardial effusions were detected after the procedures, during the non-ICU stay time. The average hospital stay was 2.19 ± 0.58 days. Conclusion The accurate selection of transthoracic echocardiographic views can better ensure the safety and effectiveness of ASD closure through the femoral vein without radiation in children.

Efficacy of a Point-of-Care Transthoracic Echocardiography Workshop for Medical Students

To assess the efficacy of a 5-week point-of-care transthoracic echocardiography workshop for medical students. Prospective, time-series design. A single institution, including students at one US medical school. The study comprised eight second- and third-year medical students. Subjects enrolled in a voluntary educational workshop designed to teach basic point-of-care transthoracic echocardiography. The primary outcome was change on the total examination score (0-100) that assessed hands-on performance of four basic transthoracic echocardiography views, identification of relevant anatomy, and echocardiography knowledge. Secondary outcomes were scores on the practical (0-40) and written (0-60) subsections of the examination. Mean and standard deviation (±SD) total examination scores increased to 83.6 (±5.2) after the workshop versus 54 (±7.1) at baseline (p < 0.0001). Mean (±SD) practical examination scores increased to 38 (±2.5) after the workshop versus 22 (±4.6) at baseline (p < 0.0001). Mean (±SD) written examination scores increased to 46 (±4.8) after the workshop versus 32 (±5.8) at baseline (p = 0.0003). Results of this pilot study indicated that the workshop curriculum may be an effective way to teach basic point-of-care transthoracic echocardiography to medical students.

Screening of Abdominal Aortic Aneurysm Using Portable Transthoracic Echocardiography among Patients with Acute Coronary Syndrome.

Background Abdominal aortic aneurysm (AAA) and acute coronary syndrome (ACS) share common risk factors. Objectives To assess the abdominal aortic diameter (AAD) among patients with ACS using transthoracic echocardiography (TTE). Methods Patients with ACS admitted to our intensive cardiac care unit from December 2013 to June 2014 were screened prospectively for AAA via AAD measurement in the subcostal TTE view. AAA was defined as an aneurysm with a transverse diameter of ≥30 mm. Results Sixty seven patients were included. The male-to-female sex ratio was 7 : 1. The vast majority of patients were admitted due to STEMI (73%), and the rest were equally divided as NSTEMI and unstable angina. The mean patient age was 58.4 ± 10.4 years. AAD measurements were feasible in 57 patients (85%); among them, AAA was diagnosed in six patients (10.5%). The average additional time required to measure the abdominal aorta was 4 ± 1 min. All patients with AAA were men and had a higher prevalence of smoking (83.3% vs. 60.6%, p < 0.003) and a lower incidence of diabetes mellitus than those without aneurysm. The prevalence of AAA tended to be related to age (12.5% in those older than 60 years and 18.7% in those older than 65 years). Conclusions The overall prevalence of AAA is significantly high among patients with ACS and increases with age. AAA screening as a part of routine cardiac TTE can be easily, rapidly, and feasibly performed and yield accurate findings. AAD measurement in the subcostal view should be implemented as a part of routine TTE in patients with ACS.

Transesophageal echocardiography instead or in addition to transthoracic echocardiography in evaluating haemodynamic problems in intubated critically ill patients

BackgroundTransesophageal echocardiography (TEE) performed by intensivists is increasingly used in critically ill patients. However, TEE is usually not the preferred monitoring tool, especially when transthoracic echocardiography (TTE) appears to have addressed the clinical problems. As a result, it remains largely unknown whether TEE is a clinically valuable replacement or supplement for TTE as a primary tool in evaluating haemodynamic problems in critically ill surgical patients. The purpose of this study was to assess the diagnostic and therapeutic value of TEE instead or in addition to TTE in critically ill surgical patients with hemodynamic instability.MethodsA prospective observational study was conducted. A total of 68 consecutive patients were enrolled from December 2016 to February 2018. TEE was routinely performed in addition to TTE, and the imaging data from TTE and TEE were successively disclosed to two different primary physicians, who reported any resulting changes in management. The two physicians were required to reach a consensus if there was any disagreement. The results of the additional TEE examination were compared with the clinical findings and TTE information. The image quality of TTE views was classified as a good (score 2), suboptimal (score 1) or poor view (score 0). According to the scores of TTE images, the patients were divided into two groups: patients with adequate TTE views (score ≥6) and inadequate TTE views (score <6).ResultsThe results of additional TEE examination were classified into four categories. TEE failed to provide additional information about the initial diagnosis and therapy (class 1) in 26 patients (38.2%). Of the remaining 42 patients (61.8%), TEE instead or in addition to TTE revealed new findings or led to significant changes in therapy, as TTE supplied inadequate information. TEE used in addition to TTE led to a new diagnosis without therapeutic implications (class 2) in 11 patients (16.2%) and made a major clinical contribution leading to a therapeutic change (class 3) in 23 patients (33.8%). TEE used instead of TTE determined the diagnosis and therapy in 8 patients (11.8%) whose haemodynamic problems could not be addressed by TTE (class 4). In total, TEE had critical therapeutic benefits (class 3 and 4) that was not provided by TTE in 31 patients (45.6%). Of particular concern was that TEE had a higher proportion of therapeutic benefits to patients with inadequate TTE views than those with adequate TTE views (54.3% vs. 27.3%, P=0.036).ConclusionsTEE as a feasible clinical tool is useful for critically ill surgical patients with hemodynamic instability, especially for the patients with inadequate TTE views. TEE instead or in addition to TTE could provide valuable information for diagnosis, which may bring significant therapeutic benefits.

Physicians\u2019 abilities to obtain and interpret focused cardiac ultrasound images from critically ill patients after a 2-day training course

BackgroundThis study aimed to determine whether a focused 2-day cardiac ultrasound training course could enable physicians to obtain and interpret focused cardiac ultrasound (FCU) images from critically ill patients.MethodsWe retrospectively reviewed the FCU images submitted by the physicians who attended a 2-day FCU training courses. Three experienced trainers reviewed the images separately. They determined whether the images were assessable and scored the images on an 8-point scale. They also decided whether the physicians provided correct responses for visual estimations of the left ventricular ejection fraction (LVEF) and right ventricle (RV) dilatation and septal motion.ResultsAmong the 327 physicians, 291 obtained images that were considered assessable (89%). The scores for parasternal short-axis view were lower than those obtained for other transthoracic echocardiographic views, p < 0.001. More physicians provided incorrect appraisals of LVEF than of RV dilatation and septal motion (19.9% vs. 3.1%, p < 0.001). The percentages of incorrect answers by LVEF category were as follows: 34.8% on images of LVEF < 30, 24.7% on images of LVEF 30–54, and 16.4% on images of LVEF ≥55%, p < 0.001. A logistic regression analysis showed that patients with abnormal LVEF were associated with physicians’ incorrect assessment of LVEF, with an odds ratio of 1.923 (95% confidence interval (CI):1.071–3.456, p = 0.029).ConclusionsA large proportion of physicians could obtain and interpret FCU images from critically ill patients after a 2-day training course. However, they still scored low on the parasternal short-axis view and were more likely to make an incorrect assessment of LVEF in patients with abnormal left ventricular systolic function.

Diagnostic Value of Transthoracic Echocardiography Combined With Contrast-Enhanced Ultrasonography in Mediastinal Masses.

Multiple types of mediastinal masses, especially masses in the anterior mediastinum, may be encountered in routine echocardiographic examinations for symptomatic or asymptomatic patients. The aim of this study was to evaluate the diagnostic value of transthoracic echocardiography combined with contrast-enhanced ultrasonography in determining the location, composition, and vascularization of mediastinal masses. A retrospective analysis was conducted on 48 consecutive patients who first had a diagnosis of mediastinal masses by echocardiography. The location of the mass, tissue components, and relationships with the heart and great vessels were analyzed on the basis of multiple transthoracic echocardiographic views. Further contrast-enhanced ultrasonography was performed to determine the vascularization of masses in 25 patients. The clinical, computed tomographic, and histopathologic findings were all recorded and analyzed. The localization, ultrasonographic characteristics of the mass, degree of vascularization, and relationships with the heart and great vessels assessed on echocardiography allowed a correct diagnosis in most of the cases. Transthoracic echocardiography is a useful method for diagnosing mediastinal. Further contrast-enhanced ultrasonography could provide more details on the degree of vascularization, which could facilitate accurate diagnosis and differentiation diagnosis.