Ultrasound Views Research Articles

3D Printed Heart Models Illustrating Myocardial Perfusion Territories to Augment Echocardiography and Electrocardiography Interpretation

Visualizing the vascular territories of coronary arteries during echocardiography or electrocardiography (ECG) requires trainees to mentally relate and overlay 2D sonographic images or cardiac lead projections with 3D anatomical representations of the ventricular walls and their respective blood supply. To facilitate the acquisition of these competencies, this study focuses on the feasibility of developing low-cost, open-sourced 3D printed heart models with standard ultrasound views or ECG lead projections illustrating the myocardial perfusion territories. A 3D digital heart model was cut to reflect the typical cardiac ultrasound views. The 4-chamber view model was further punctured for the paths of the precordial and limb leads of an ECG. Painting coronary arteries on the surface and internal views of the 3D prints illustrated vessel territories. Students, residents, and staff were surveyed during bedside ultrasound simulation sessions and ECG teaching half-days. Results demonstrated clear appreciation of 3D printed models, which suggests such models can easily be implemented by other institutions to augment trainees' experience during skill acquisition.

Extended Cranial Ultrasound Views in Infants with Acute Brain Stem/Infratentorial Lesions: Diagnosis of a Progressive Midline Glioma in a 6-Week-Old Infant

AbstractCentral nervous system (CNS) tumors are the most common solid tumors in children and adolescents. However, in neonates and children aged younger than a year, they are very rare. Clinical presentation in neonates is often subtle and nonspecific. When neurological symptoms are apparent at this age, cranial ultrasound (CUS) is often done as the initial evaluation, with a standard approach through the anterior fontanel (AF), followed by further imaging, such as magnetic resonance imaging (MRI), if necessary. We report the first neonatal case of a rapidly progressive diffuse midline glioma positive for histone H3 K27M mutation (World Health Organization [WHO] grade IV) in which using extended (transmastoid) CUS studies through the mastoid fontanelle (MF) in the second month of life defined the lesion in the brainstem.

Усиление эхо-сигнала от перикарда у реципиентов вакцин против SARS-CoV-2

The full-scale syndrome of pericarditis or subclinical changes in pericardium, as seen during transthoracic echocardiography, are detected in large number of patients with COVID-19 or or those who have recovered from COVID-19, and can persevering for about a year. There is a significant accumulation of reported cases of pericarditis following vaccination against SARS-CoV-2. Questions remain about subclinical pericardial involvement in vaccinated patients. The study is aimed to examine pericardial changes through transthoracic echocardiography in patients vaccinated against SARS-CoV-2, and describe their dynamics and compare the ultrasound views with symptoms and inflammatory changes in blood tests. Methods. Inclusion criteria: The patient’s consent, the intention to be vaccinated against SARS-CoV-2, no confirmation and suspicions about COVID-19 in the past, unchanged pericardium as of Visit 0, as well as no diseases which may cause any changes in the pericardium throughout the time of the study. Exclusion criteria: SARS-CoV-2 infection during the study, refusal or any impossibility to make more as 1 scheduled visit for check-up. Echocardiography was performed according to a standardized protocol at unchanged brightness settings with a focus on the pericardium in dynamics: before the vaccination (Visit 0), within a week after the first dose (Visit 1) and the second dose (Visit 2), and in a month (Visit 3), 2 months (Visit 4), 3 months (Visit 5) and 4 months (Visit 6) after the latest dose of the vaccine. Complete venous blood count with a leucogram and determination of the erythrocyte sedimentation rate was performed at visits 0 and 2. Results. 52 patients completed their participation in the study. Low-intensity changes in the pericardium after the first dose of the vaccine were found in 67% of patients. Ultrasound changes arose as a more enhanced echocardiographic signal in the basal segments of the inferolateral area in 57%, spread up to the basal segment of the anterior lateral area in 13%, the area around the atria in 15%. Pericardial layer separation for 3 and more mm was found in 23%. After the second dose of the vaccine was administered, 74% demonstrated the enhancement of the pericardium, including signs of minor effusion in 20% of patients. The pericardium image got slightly less bright in 4 ± 1 weeks after the second dose: up to the conditional normal state (the visual quality of the pericardium in a specific person as of visit 0) in 2 patients. However, the pericardium remained brighter in 71%, with the minimal effusion in 1 patient. 68% of patients demonstrated the pathological TTE image in the 8th week after the vaccination, with effusion being discovered in 2% of patients. The hyperechogenity of the pericardium was detected in 66% in 12 ± 1 weeks, without effusion being found. The pericardium still remained brighter in 16 ± 1 weeks in 7% of patients than it was before the vaccination. Low-intensity pericardial chest pain is detected only with active questioning and is recorded in up to 8% of cases in the first 4 days after the administration of the 1st and /or 2nd doses of the vaccine, did not correlate with the duration of hyperechogenity, but did- with exudation: r = 0,22 (p = 0,05). Of the analyzed blood parameters, an increase in the percentage of neutrophils by 2.8% was registered after vaccination, the increase in their proportion correlated with the presence of a combined point, including any of the considered echo parameters of the pericardium, at visit 2: r = 0.5, p < 0, 05; in 6% of patients, neutrophils exceeded normal values. Also, after vaccination, the erythrocyte sedimentation rate significantly increased (on average, by 4.2 mm/h), which correlated with the presence of a combined point of pericardial changes (r = 0.6, p < 0.05). The erythrocyte sedimentation rate threshold was exceeded in 12% of the subjects: all of them had a recorded effusion according to echocardiography. The appearance of band forms neutrophils by 1 week after the administration of the 2nd dose of the vaccine was registered in 50% of patients. None of the observed required hospitalization and died. Conclusion. The overwhelming majority of patients demonstrated the TTE phenomenon of the enhanced or effused pericardium as a result of the vaccination. Minimal changes completely disappeared in 4 months. The presence of ultrasound changes in the pericardium correlates with an increase in erythrocyte sedimentation rate and / or the proportion of neutrophils is accompanied by a stab shift in 50% of the analyzes. We believe more aimed research is needed to evaluate systemic effects of virus antigens on the body. Drawing upon the experience of the center, the above TTE changes are much less intense in terms of TTE signs than it happens after contacting a live pathogen. Therefore, it can definitely be more preferable than “natural” immunization due to illness Key words: COVID-19, complications, echocardiography, pericarditis, vaccination

Use of Ultrathin Bronchoscope on a Need Basis Improves Diagnostic Yield of Difficult-to-Approach Pulmonary Lesions.

There are cases of peripheral lung nodules that are difficult to approach despite using ancillary diagnostic devices during multimodal bronchoscopy. The use of ultrathin bronchoscopes has shown superiority over standard thin bronchoscopes. We retrospectively evaluated whether substitution of the thin-bronchoscope by the ultrathin device during multimodal bronchoscopy improves lesion ultrasound visualization and diagnostic yield in patients with difficult-to-approach pulmonary lesions. The study comprised 44 out of 338 patients that underwent multimodal bronchoscopy at Matsusaka Municipal Hospital. The thin-bronchoscope with an external diameter of 4 mm was substituted by the ultrathin-bronchoscope with an external diameter of 3 mm when the radial endobronchial ultrasound showed that the probe position was not within the target lesion. The median diameter of the pulmonary tumors was 17.5 mm (range: 6.0–5.2.0 mm). The endobronchial ultrasound showed the probe's position adjacent to the lesion in 12 cases and no visible lesion in 32 cases using a thin-bronchoscope. However, the endobronchial ultrasound views changed from adjacent to the lesion to within the lesion in nine cases, from no visible lesion to within the lesion in 17 cases, and from no visible lesion to adjacent to the lesion in nine cases after bronchoscope substitution. After substitution, the diagnostic yield was 80.8% in cases with the radial probe within the target lesion, 72.7% in cases with the probe adjacent to the target lesion, and 0% in cases with no visible lesion. The overall diagnostic yield was 65.9% after bronchoscope substitution. The substitution of the thin bronchoscope by the ultrathin device on a need basis improves the position of the radial endobronchial ultrasound probe and diagnostic yield of pulmonary lesions during multimodal diagnostic bronchoscopy.

Real-Time Remote Tele-Mentored Echocardiography: A Systematic Review.

Background and Objectives: Real-time remote tele-mentored echocardiography (RTMUS echo) involves the transmission of clinical ultrasound (CU) cardiac images with direct feedback from a CU expert at a different location. In this review, we summarize the current uses of RTMUS to diagnose and manage cardiovascular dysfunction and discuss expanded and future uses. Materials and Methods: We performed a literature search (PubMed and EMBase) to access articles related to RTMUS echo. We reviewed articles for selection using Covidence, a web-based tool for managing systematic reviews and data were extracted using a separate standardized collection form. Results: Our search yielded 15 articles. Twelve of these articles demonstrated the feasibility of having a novice sonographer mentored by a tele-expert in obtaining a variety of cardiac ultrasound views. The articles discussed different technological specifications for the RTMUS system, but all showed that adequate images were able to be obtained. Overall, RTMUS echo was found to be a positive intervention that contributed to patient care. Conclusion: RTMUS echo allows for rapid access to diagnostic imaging in various clinical settings. RTMUS echo can help in assessing patients that may require a higher level of isolation precautions or in other resource-constrained environments. In the future, identifying the least expensive way to utilize RTMUS echo will be important.

Can non-physician advanced retrieval practitioners (ARP) acquire and interpret diagnostic views of the lungs with sufficient quality to aid in the diagnosis of pneumothorax in the pre-hospital and retrieval environment?

BackgroundAs an adjunct to physical examination, ultrasound is a potentially attractive option for diagnosing pneumothoraces in the pre-hospital and retrieval environment – and could confer a benefit to patient safety. However, the published evidence supporting non-physicians use of ultrasound in this setting is limited.AimWe aimed to establish if Advanced Retrieval Practitioners (non-physicians) could acquire ultrasound views of the lungs and interpret them with sufficient quality to diagnose pneumothorax in the pre-hospital and retrieval environment when compared to expert review.MethodThe study consisted of an observational trial from April 2017 to April 2018. Twelve (12) patients bilateral lung ultrasound images (24 images) were randomly selected from 87 patients assessed using Point of Care Ultrasound (POCUS) by three Advanced Retrieval Practitioners in the Pre-hospital and Retrieval environment. Two expert reviewers’ evaluated these images to determine ARPs ability to acquire diagnostic quality images and interpret them correctly. CXR results of patients in whom lung ultrasound was undertaken were recorded as the reference standard investigation.ResultsWithin the 22 images considered adequate by the Advanced Retrieval Practitioners, 19 (86.4%, one-tailed McNemar test p = 0.125) were considered adequate on expert review. Of the 19 images mutually considered as adequate, both the Advanced Retrieval Practitioners and the reviewers identified two pneumothoraces which were subsequently confirmed on chest x-ray (Sensitivity 100% and Specificity 100% in technically adequate images). One pneumothorax was detected on CXR in a patient with inadequate ultrasound images. Advanced Retrieval Practitioners were therefore able to both obtain adequate images and correctly diagnose pneumothorax in the pre-hospital environment with 66.6% sensitivity (95%CI 66.6–100%) and 100% specificity (95%CI 81.0–100%) compared to expert review.ConclusionAdvanced Retrieval Practitioners (non-physicians) can obtain diagnostic views of the lungs of sufficient quality to diagnose the presence, or particularly the absence, of pneumothorax in the pre-hospital and retrieval environment. Although Advanced Retrieval Practitioners were less accurate than the expert reviewers at interpreting the quality of the ultrasound images, the result was not statistically significant, despite the ARPs possibly having been at a methodological disadvantage.

VP17.19: The use of three vessels and trachea view in second trimester ultrasound for the diagnosis of cardiac malformations

To determine the use of three vessels and trachea (3VT) view in fetal second trimester cardiac scanning for the diagnosis of cardiac malformations. We analysed all the second trimester ultrasounds in a terciary referring centre during 5 years (N: 10092). We performed a retrospective study of 66 women diagnosed of fetal cardiac malformations in this ultrasound scan (0.71%). The 3VT view is an ultrasound transverse plane in the upper mediastinum. The abnormalities detected were confirmed postnatally by a pediatric cardiologist, echocardiography or autopsy. 52 of the 66 fetuses (78.79%) showed an abnormal 3VT view. We classified the lesions according to the most evident abnormal ultrasound finding. Abnormal vessel size was found in 40.38%. Abnormal colour Doppler pattern with turbulent flow or reverse flow was found in five fetuses with outflow tract stenosis. Abnormal vessel alignment and arrangement was found in 3 fetuses. Abnormal vessel number was found in 7 fetus (3 fetus with two vessels instead of three and 4 fetus with four vessels instead of three). Abnormal location of vessels in relation to the trachea was found in 39.39%. This ultrasound view is very reliable in the diagnosis of an important group of critical heart defects involving the outflow tracts and the aortic arch. The three vessels and trachea view, with the contribution of colour Doppler, is a good and easy method for screening heart defects. VP17.19: Table 1.

170 Use of Transthoracic Ultrasound to Confirm Placement of Resuscitative Endovascular Balloon Occlusion of the Aorta in Medical Cardiac Arrest

The objective of this study is to assess the feasibility of using bedside ultrasound to visualize and confirm aortic placement of resuscitative endovascular balloon occlusion of the aorta (REBOA) within an emergency medicine (EM)-initiated multi-disciplinary protocol in non-traumatic OHCA. REBOA is a hemorrhage control technique involving the intra-vascular occlusion of the thoracic aorta using a balloon catheter and may help to increase coronary and cerebral perfusion during non-traumatic out-of-hospital cardiac arrest (OHCA) by directing blood flow to the upper body. We are conducting a single-arm early feasibility study of REBOA initiated in the emergency department (ED) for OHCA using an investigational device approval by the Food and Drug Administration (FDA) with an exception from informed consent. During CPR, an emergency physician obtains common femoral access using a 7Fr introducer sheath while the REBOA catheter is prepared and subsequently advanced by an interventional radiologist (IR). While sheath introducer placement can be confirmed with ultrasound views of the common femoral artery, we seek to confirm intrathoracic REBOA placement using transthoracic bedside ultrasound. Our goal is to enroll 20 patients into this study and use transthoracic ultrasound to confirm REBOA placement in each. Two of the initial twenty patients were enrolled between January and February 2020, with a temporary pause in enrollment due to the COVID pandemic from March to July 2020. In both enrolled patients, transthoracic views were obtained confirming intra-thoracic aortic placement of REBOA by an emergency physician. In our initial two cases, thoracic aortic placement of the REBOA in non-traumatic OHCA was confirmed by emergency physicians using transthoracic ultrasound. This demonstrates correct placement of aortic endovascular devices can be confirmed using emergency physician operated ultrasound. Further research is needed to determine what factors may impact emergency physicians’ ability to successfully identify and confirm aortic device placement.

Evaluation of the Lower Trapezius Muscle Using Ultrasound Panoramic View (a Novel Approach): An Intra- and Inter-Rater Reliability Study.

The panoramic view ultrasound remains uncommon in clinical practice, probably because of its difficulty, high-cost, and lack of research. Morphological changes in muscles have been demonstrated to be related to symptomatology and provide data of interest for clinical assessment. Thus, the aim of this study was to evaluate the measurement reliability of the length of the lower trapezius muscle with the panoramic view ultrasound using a novel tool, SIG_VIP®. Twenty healthy volunteers were measured by two expert sonographers using the SIG_VIP® tool with a novel approach. Statistical analyses were performed with the R software. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC), and Bland-Altman plots were calculated. All the results indicated good intra-rater reliability (ICC3,1, 0.92 to 0.96; SEM, 0.59 to 0.85; MDC, 1.64 to 2.35) and inter-rater reliability (ICC3,2, 0.84 to 0.89; SEM, 1.22 to 1.53; MDC, 3.39 to 4.25). The novel system used with the described methodology can reliably measure the length of the inferior fibers of the trapezius muscle. Further research must be conducted to evaluate the reliability in patients and how pathology is related to the length of the lower trapezius muscle.

Cross-sectional area of the cervical extensors assessed with panoramic ultrasound imaging: Preliminary data in healthy people

BackgroundStudies analyzing morphometry of neck extensor musculature have mostly used Magnetic Resonance Imaging (MRI). Panoramic Ultrasound View could be used for obtaining high-quality 2D cross-sectional images with a wide field of view more cost-effectively imaging acquisition by creating an automatic construction of 2D cross-sectional images. ObjectiveTo measure neck extensors cross-sectional area (CSA) using panoramic ultrasound view in healthy subjects. DesignCross-sectional study. MethodsPanoramic B-mode ultrasound images of the neck extensor muscles at C4/C5 level were acquired in 25 healthy subjects (40% women, mean age: 24 ± 5 years) by an experienced assessor. The CSA of the upper trapezius, splenius (layer), semispinalis (layer), multifidi, short rotators, and levator scapulae were calculated. The relative percentage in the total neck extensor muscle volume of each CSA was also determined. Sex and side-to-side comparisons were conducted. ResultsMen showed larger CSAs than women in all muscles (all, P < 0.01). No side-to-side differences were found in either men or women (all, P > 0.05). Significant positive associations between CSA with weight (r: 0.654 to 0.375, P < 0.01), height (r: 0.386 to 0.581, P < 0.05), and BMI (r: 0.369 to 0.563, P < 0.05) were found. Men showed greater percentage of upper trapezius and semispinalis muscle layers than women (P < 0.01), whereas women had a greater percentage of levator scapulae muscle than men (P < 0.01) from the total volume of the neck extensors. No side-to-side differences were found either. ConclusionsThe current study describes CSA, as assessed with panoramic ultrasound view, of the neck extensors in healthy people. Men exhibited greater CSA than women with no side-to-side differences.

Precision Medicine with 3D Ultrasound.

Introduction: Currently, B-mode ultrasound (US) is the primary imaging modality in diagnosing thyroid nodules (TNs). B-mode is a two-dimensional US (2D US) imaging display. Recent studies suggest a role for strain and shear wave elastography for evaluating TN as well. Three-dimensional US (3D-US) has the potential to enhance the diagnostic accuracy and precision for thyroid cancer (TC) detection.Materials and Methods: An experienced ultrasonographer (G.A.) evaluated the patient using the following techniques: B-mode, strain and shear wave elastography, and 3D-US followed by fine needle aspiration biopsy (FNAB). Laboratory measurements were performed at LabCorp. Informed consent was obtained.Case: A 28-year-old woman referred for hypothyroidism. Her primary doctor initiated levothyroxine 50 mcg daily 6 months prior. At the time of her visit, her thyroid stimulating hormone (TSH) was 2.8 (0.45–4.5 uIU/mL) and both thyroid peroxidase and thyroglobulin antibodies were elevated, suggestive of Hashimoto's thyroiditis. Her thyroid US showed a heterogeneous gland with an isoechoic TN in the right lobe measuring 7.7 × 6.3 × 7 mm. Strain elastography showed diffuse and patchy tissue stiffness throughout the gland, suggestive of tissue fibrosis caused by Hashimoto's thyroiditis. This study did not distinguish target TN from the surrounding tissue. Shear wave elastography of the TN revealed moderately increased stiffness compared with surrounding tissue. The shear wave velocity (SWV) measurement for the TN was 3.1 m/s. 3D-US examination demonstrated an isoechoic TN with irregular margins, and the volume was 0.119 cm3. FNAB of the TN was performed. Cytopathology was diagnostic for papillary thyroid cancer (PTC), Bethesda Category VI. Subsequent total thyroidectomy confirmed a 7 mm PTC with positive surgical margins caused by thyroid capsule invasion and no clear-cut evidence of extra-thyroid extension.Discussion: This case showcases the recent technological advances in TN imaging. Our objective is to provide an improved approach to TN management. The American College of Radiology Thyroid Imaging Reporting and Data System stratifies the malignancy risk of TN primarily based on the size and B-mode US features. This model does not recommend FNAB for any TN <10 mm regardless of malignancy risk.1 This is our observation that with 3D-US the size cutoff of TN might not be an issue as with B-mode or elastography. Irregularities of the TN can be seen with 3D-US with small and large nodules equally. The finding of irregular margins on 3D-US and consulting with the patient lead us to perform FNAB. Recent publications in the journal of VideoEndocrinology showed utilizations of 3D-US in diagnosing parathyroid adenomas and TNs. 3D-US technology improves view of the target lesion by adding a third dimension, coronal view, to the transverse and longitudinal views of B-mode US.2,3 B-mode imaging provides excellent view of TNs. However, it has a low sensitivity for predicting TC.4 Prospective TN studies have demonstrated that adding elastography to B-mode imaging improves sensitivity of US technology for detecting TC.5–10 In a prospective study with 707 TN, we showed that a single cutoff analysis for predicting malignancy in TNs, a maximum SWV of 3.54 m/s had the best sensitivity. The mean SWV for benign nodules was 2.71 m/s. The mean SWV for malignant nodules was 3.96 m/s.6 In this particular case strain and shear wave were not as helpful. The discrepancy between the two systems has been described in cases with severe Hashimoto's thyroiditis associated with tissue fibrosis.6 In our experience, the presence of autoimmune thyroid disease increases the risk for malignancy. Recent publications reported an association between differentiated TC and autoimmune thyroid disease and/or TSH when all Bethesda classifications were included.11–13Conclusion: 3D-US technology in conjunction with B-mode may improve diagnostic accuracy in detecting TC.No competing financial interests exist.Runtime of video: 2 mins 30 secs

Internal Jugular Vein Cannulation Using a 3-Dimensional Ultrasound Probe in Patients Undergoing Cardiac Surgery: Comparison Between Biplane View and Short-Axis View

To compare the clinical performance in terms of procedure time, success rate, and cannulation attempts between ultrasound biplane view (BPX) and short-axis (SAX) view for internal jugular vein cannulation (IJV) in patients undergoing cardiac surgery. Prospective, observational pilot study. University level tertiary referral hospital. The study comprised 100 patients between ages 18 and 75 years undergoing elective cardiac surgery. One hundred patients were divided into 2 groups of 50 (BPX group and SAX group) by assigning the study participants alternatively to each group. IJV cannulation was performed using a 3-dimensional ultrasound probe in all patients with either BPX view (BPX group, n = 50) or the SAX view (SAX group, n = 50) by an experienced anesthesiologist. Time required for imaging, time for IJV puncture, time for guidewire confirmation, number of needle punctures and needle redirections, and incidence of posterior wall puncture were noted in both groups. In addition, the quality of needle visualization and the incidence of complications were recorded. The time taken for imaging was significantly greater in the BPX group than in the SAX group (9.52 ± 2.69 s v 7.94 ± 2.55 s; p = 0.0034), whereas the time taken for IJV puncture (10.39 ± 2.33 s v 23.7 ± 2.46 s; p < 0.0001), time taken for confirmation of guidewire (32.94 ± 4.50 s v 57.64 ± 7.14 s; p < 0.0001), and the incidence of posterior wall puncture (4% v 26%; p = 0.0022) were significantly less in the BPX group than in the SAX group. The total number of attempts taken to puncture the IJV was fewer in the BPX group than in the SAX group (55 v 78). Successful puncture of the IJV occurred on the first attempt in 90% of patients in the BPX group, whereas it was only 50% in the SAX group (p < 0.0001). The quality of needle visualization was good in 90% of patients in the BPX group, whereas it was only 6% in the SAX group. The number of needle redirections for IJV puncture was less in the BPX group than in the SAX group (48 v 116). The incidence of complications was not significant between the 2 groups. The results suggested that the BPX view may be a safer, feasible and more reliable method than the SAX view for IJV cannulation in cardiac surgical patients.

Caudal vena cava collapsibility index in healthy cats by ultrasonography

ABSTRACT The objective of this study was to calculate the collapsibility index (CI) in a group of 15 healthy adult mixed breed cats via right hepatic intercostal ultrasound view. The minimal and the maximal diameters of the caudal vena cava (CVC) were obtained during inspiration and expiration, respectively, then CI was calculated. The mean diameter of the CVC was 0.5cm. The mean CI was 28±3% and CI was not significantly associated with gender. As in human medicine, there is a growing need for less invasive monitoring in small animal practice. The CI enables the assessment of estimated volemia without the need for a central venous catheter. This is the first reported study investigating CI in cats.

Maternal-fetal surgery during the coronavirus disease 2019 pandemic

Maternal-fetal surgery during the coronavirus disease 2019 pandemic

Cutting to the Chase: Sectioned Plastinated Heart Models Improved Performance and Confidence in Cardiac Ultrasound

At the University of Colorado School of Medicine, hands‐on ultrasound (US) labs are incorporated into medical and graduate gross anatomy courses. In regional US labs, students perform live US scanning to learn the basics of a clinical skill and image interpretation, while reviewing key anatomy concepts. Cardiac US scanning is particularly challenging due to heart position in the thorax, and standard US views (parasternal long axis/PLAX and parasternal short axis/PSAX) differing from typical imaging and dissection views. The study aimed to evaluate 3D plastinated heart models sectioned in PLAX &amp; PSAX views as resources during novice US training.In an IRB exempt study, eight plastinated human hearts were sectioned along standard US views (4 PLAX, 4 PSAX) creating 3D‐sectioned models. Graduate gross anatomy students (N=25) were recruited during a scheduled cardiac US lab. Small groups performed cardiac scanning for 50 minutes with instructions and PLAX/PSAX views handout. Students then received a survey with 7 Likert questions of self‐confidence in heart position, PLAX and PSAX probe orientation, and anatomical structure recall and identification. Students were assessed on 8 multiple choice questions (MCQ) categorized as Anatomical Identification (N=2), US View Identification (N=3), or Combined US &amp; Anatomy (N=3). Next, groups received a PLAX‐sectioned heart model with repeat PLAX/PSAX scanning instructions and views handout. After 20 minutes scanning with models, students received another Likert survey (2 repeat self‐confidence items &amp; 9 items on 3D‐sectioned heart models as aides) and MCQ quiz of 8‐items matched to pre‐quiz. Due to time, PSAX‐sectioned models were not provided.Participant responses (n=25, 100% response rate) showed PLAX‐sectioned models perceived useful for learning PLAX US (100% agreement; ratings 4 or 5) and sectioned heart models would be useful in learning PSAX (96% agreement). Self‐perceived confidence in PLAX and PSAX probe orientation significantly improved after PLAX‐sectioned model use (Mann‐Whitney U Tests, both p&lt;0.05). Statistical analysis showed overall significant improvement on MCQ assessment after PLAX sectioned model use (Mann‐Whitney U, p&lt;0.05). Performance within MCQ categories showed changes after PLAX model usage in Anatomical Identification (10–25% increase), US View Identification (range of −4‐2% change), and Combined (0–24% increase). No statistical significance (McNemar, p&gt;0.05) was seen on individual questions within each category, except one Anatomical Identification question (McNemar, p&lt;0.05).The PLAX‐sectioned heart models were perceived as useful resources for learning basic cardiac US, specifically for learner confidence orientating probes in standard US views. Overall, MCQ performance improved after PLAX‐sectioned heart model use. Improvement could not be linked to a specific item category possibly due to small sample size. Plastinated heart models may be a valuable resource for learning cardiac US early in medical training, especially given scanning complexity and time constraints in gross anatomy courses.

Thin Fluttering Bands: New Findings in the Carotid Evaluation

The aim of this study was to investigate the prevalence, characteristics, and possible clinical impact of the thin fluttering bands detected by carotid ultrasound. This is a prospective, observational study carried out in a single center between 2016 and 2018. A thin fluttering band was defined as a hyperechoic fluttering band detected by ultrasound in the carotid lumen in absence of findings compatible with pattern of dissection. Intraobserver and interobserver variability were carried out. A total of 3440 patients (p) were evaluated by carotid ultrasound, and thin fluttering bands were detected in 118 p (prevalence of 3.43%). The mean age was 58.9 ± 8.5 years and 48 p (40.7%) were male. In total, 97.5% of patients had no symptoms or neurological history. A total of 134 thin fluttering bands were identified (1.13 TFB/p; 104 p with 1 thin fluttering band, 12 p with 2 thin fluttering bands, and 2 p with 3 thin fluttering bands), and 83% of them were visualized from both longitudinal and transversal ultrasound views. Seventy-seven (57.5%) thin fluttering bands were localized on the right side, with the carotid bifurcation as the most common location (127 thin fluttering bands, 94.8%). The mean length of the bands was 5.6 ± 2.6 mm, with no significant differences in size according to the location, intima media thickness, or presence of carotid plaques. No significant interobserver and intraobserver variability was found. In conclusion, we have presented patients with thin fluttering bands, observing a significant prevalence in our population and ruling out a visual artifact. Their relationship with the genesis of atheroma plaques or its possible neurologic impact remains unclear.

Development and testing of a low cost simulation manikin for extracorporeal cardiopulmonary resuscitation (ECPR) using 3-dimensional printing

BackgroundThere has been an explosive growth of ECPR within new and established ECMO programs worldwide with the concomitant need for simulation trainers. However, current commercially available ECMO simulation models are expensive and lack many standard cardiorespiratory resuscitative (CPR) features. ObjectiveTo use 3-dimensional (3D) printing to develop a training manikin for comprehensive ECPR simulation. MethodsA standard commercially available CPR manikin with airway model was used as the base model for modification. An inexpensive 3D printer was used to print a modular plastic pelvis. A medical silicone gel incorporated silicone femoral vasculature component was manufactured with connection to a gravity fed vascular system. ResultsThe resulting modified manikin included the modular in-house designed ECMO cannulation and vascular structures wedded to the commercially available airway and CPR components. In simulation exercise involving first responders, paramedics, and emergency and critical care physicians, the model was reported as realistic with ultrasound views, cannulation, and resuscitative components functional. The entire cost for development of the ECMO component was estimated at $2000 Australian dollars AUD, including the printer purchase and supplies. Future reuse of components is estimated to cost less than $5 AUD per simulation run. ConclusionsA novel in-house modified manikin for ECPR was developed that was cost-efficient and realistic to use from first response through to establishment of ECMO circulation.

Convolutional-Neural-Network-Based Approach for Segmentation of Apical Four-Chamber View from Fetal Echocardiography

An apical four-chamber (A4C) view from early fetal echocardiography is an extremely significant step in early diagnosis and timely treatment of congenital heart diseases. The objective is to perform automated segmentation of cardiac structures, namely, the epicardium, left ventricle, left atrium, descending aorta, right atrium, right ventricle, and thorax, in ultrasound A4C views in one shot in order to assist clinicians in prenatal examination. However, such a segmentation task is often faced with the following challenges: 1) low imaging resolution; 2) incomplete tissue boundary; 3) overall contrast of the image. To address these issues, in this study, we propose a cascaded U-net, named CU-net, with structural similarity index measure (SSIM) loss. First, the CU-net with two branch supervisions helps gain clear tissue boundaries and alleviate the gradient vanishing problem caused by increasing network depth. Second, between-net connections in the CU-net can transmit the prior information from the shallow layer to the deeper layer and obtain more refined segmentation results. Third, the method leverages on SSIM loss to preserve fine-grained structural information and obtain clear boundaries. Extensive experiments on a dataset of 1712 A4C views demonstrate that the proposed method achieves a high dice coefficient of 0.856, Hausdorff distance of 3.33, and pixel accuracy of 0.929, revealing its effectiveness and potential as a clinical tool.

Ultrasound Guided Paramedian versus Landmark Guided Midline Technique for Spinal Anaesthesia- A Randomised Clinical Trial

Introduction: Spinal anaesthesia has been traditionally performed using landmark guided technique. Ultrasound helps in identifying the insertion point, depth, as well as angle of the needle advancement by visualisation of the neuraxial structures, thus, increasing the probability of successful dural puncture. Aim: To compare the success rates of dural puncture at first attempt between Preprocedural Ultrasound (PUS) guided paramedian and landmark guided midline approach in spinal anaesthesia. Materials and Methods: This was a randomised clinical study, conducted at a Tertiary Care Hospital during May 2017-December 2018. Patients (n=110) undergoing lower limb orthopaedic surgery were randomly allocated into group US (PUS guided with paramedian approach) and group LM (landmark guided with midline approach), with 55 patients each. Number of attempts and passes, procedure time, any complication, periprocedural pain and patient satisfaction were noted. The correlation between quality of ultrasound view and success rate was also analysed using Fisher’s-exact test. Results: The success rate of dural puncture at first attempt was 89.09% in US group versus 76.36% in LM group, p&gt;0.05. Total number of needle insertion attempts (1.31±0.63 in group LM, 1.11±0.31 in group US, p&gt;0.05) were comparable. Total procedure time was higher (11.96±1.55 minutes) in US group as compared to LM group (3.26±0.68 minutes), p&lt;0.001. Periprocedural pain score was significantly lower in US group with p&lt;0.01. The patient satisfaction score was comparable in the two groups, p&gt;0.05. Correlation between the quality of parasagittal oblique view and success rate of dural puncture was good, p&lt;0.01. Conclusion: PUS guided paramedian approach does not significantly increase the success rate at first attempt as compared to midline landmark guided approach.

The parasternal long axis ultrasound view does not allow the maximum diameter of the aortic root to be measured in atypical BAV

Following guidelines, maximal aortic root diameter has to be measured in parasternal long axis (PLA TTE) view in trans-thoracic echocardiography (TTE). However, asymmetry of the aortic root is common in BAV and the largest diameter might be missed when using PLA TTE. Assess whether the maximum aortic diameter measured with PLA TTE and CT differs according to the type of BAV. Eighty-six patients with BAV without significant valvulopathy referred for aortic aneurysm assessment and who had benefited from TTE and CT were studied. Typical BAVs have a horizontal valve opening (type I L-R and type 0 anteroposterior) while atypical BAVs have a vertical valve opening (type I N-R and type 0 lateral) ( Fig. 1 ). We compared: – In CT, using the sagittal plane as a reference, the orientation of the largest diameter of the aortic root in typical and atypical BAVs ( Fig. 1 ); – the difference of the maximal aortic root diameter measured with PLA TTE and CT in typical and atypical BAVs. When comparing maximal aortic root diameter measured in PLA TTE and CT: in the whole cohort, PLA TTE underestimates the maximal aortic root diameter with a mean difference of 3 mm In atypical BAVs, the difference between CT and PLA TTE is 6,0 mm significantly different from the 2.3 mm found in typical BAVs P = 0.0008 ( Fig. 1 ). The orientation of the maximal aortic diameter is correlated with the type of BAV: Using the sagittal plan as a reference, this angle is 64.3° for the typical BAV and 143.1° for the atypical BAV P < 0.0001 ( Fig. 1 ). In typical BAVs, the maximal root diameter has the same direction that ultrasound beam (red arrow) while in atypical BAVs, the ultrasound beam is perpendicular to the maximum aortic diameter. The different orientation of the maximal diameter of the aortic root in atypical vs. typical BAVs explains the inability to measure the maximum aortic diameter in PLA TTE for the atypical BAVs.