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

Use of hand-carried ultrasound devices to augment the accuracy of medical student bedside cardiac diagnoses

BACKGROUND

Hand-carried ultrasound (HCU) devices used by cardiologists as extensions of the physical examination have been shown to improve the accuracy of bedside diagnoses. We tested the feasibility of teaching medical students to use HCU devices to make bedside cardiac diagnoses and compared the accuracy of their HCU and physical examinations.

METHODS

In all, 10 fourth-year medical students enrolled in a 4-week medical school course on the cardiac examination. Students examined 12 standardized patients at 3 different time intervals: (1) on day 1 of the course; (2) on day 10 after review of cardiac physical examination using traditional teaching methods; and (3) after instruction on the use of HCU devices. Students were scored at each time interval for primary findings (most salient) and all findings, accounting for both errors of commission and omission. Scores could range from +12 to -12 for primary findings and from +22 to -22 for all findings. A perfect score was +12 for primary findings and +22 for all findings.

RESULTS

The average score for all students at baseline was -3.2 +/- 3.1 and -5.7 +/- 4.8 for primary and all findings, respectively. A significant improvement in the scores was noted with use of the HCU device (2.6 +/- 3.1 and 5.2 +/- 6.6 for primary and all findings, respectively) compared with the baseline and two subsequent physical examinations.

CONCLUSION

Instruction of fourth-year medical students on the use of HCU device is feasible and results in significantly more accurate bedside diagnoses.

Technology Insight: hand-carried ultrasound cardiac assessment—evolution, not revolution

Hand-carried ultrasound devices can enhance the art of bedside physical examination by increasing diagnostic accuracy, detecting disease at an earlier stage, and improving triage and referral of patients. Although limitations of device cost and portability can be overcome with technologic advances, the shortage of standardized imaging and training opportunities now needs to be addressed to move the technique forward. Cardiologists are the best-qualified subspecialists to design and teach a simplified training program for bedside use of hand-carried ultrasound devices to assess the cardiovascular system.

Hand-held echocardiography: added value in clinical cardiological assessment

BACKGROUND

The ultrasonic industry has recently produced echocardiographic Hand Held Devices (miniaturized, compact and battery-equipped echocardiographic systems). Their potential usefulness has been successfully assessed in a wide range of clinical conditions. The aim of the study was to verify if the routine use of a basic model of echocardiographic Hand Held Device (HHD) could be an important diagnostic tool during outpatient cardiologic consulting or in non-cardiologic hospital sections.

METHODS

87 consecutive patients were included in this study; they underwent routine physical examination, resting ECG and echocardiographic evaluation using a basic model of HHD performed by trained echocardiographists; the cardiologist, whenever possible, formulated a diagnosis. The percentage of subjects in whom the findings were judged reasonably adequate for final diagnostic and therapeutic conclusions was used to quantify the "conclusiveness" of HHD evaluation. Successively, all patients underwent a second echocardiographic evaluation, by an examiner with similar echocardiographic experience, performed using a Standard Echo Device (SED). The agreement between the first and the second echocardiographic exam was also assessed.

RESULTS

Mean examination time was 6.7 +/- 1.5 min. using HHD vs. 13.6 +/- 2.4 min. using SED. The echocardiographic examination performed using HHD was considered satisfactory in 74/87 patients (85.1% conclusiveness). Among the 74 patients for whom the examination was conclusive, the diagnosis was concordant with that obtained with the SED examination in 62 cases (83.8% agreement).

CONCLUSION

HHD may generally allow a reliable cardiologic basic evaluation of outpatient or subjects admitted to non-cardiologic sections, more specifically in particular subgroups of patients, with a gain in terms of time, shortening patient waiting lists and reducing healthy costs.

The value of portable ultrasound for evaluation of cardiomegaly patients presenting at the emergency department

OBJECTIVES

The purpose of this study was to evaluate the value of a hand-carried portable ultrasound device in the emergency department for patients with cardiomegaly and evaluate its impact on diagnosis and treatment. We compared the results of the portable ultrasound with the results of physical examination and with standard echocardiograph (SE) in the cardiomegaly patients in emergency department.

BACKGROUND

Recently, small portable ultrasound devices have been introduced, and they need more extensive study to evaluate their application.

METHODS

We used the OptiGo (Agilent Technologies, Andover, MA) portable device to evaluate emergency patients, and compared it with two SE devices available for this study, the Hewlett Packard (Sono 5500; Andover, MA) or the Vingmed (System V; Horten, Norway). Each of 100 patients was studied by physical examination first then examined with the portable ultrasound and standard echocardiography. The yields from physical examination and portable echocardiography were compared and results of the standard and portable were also compared.

RESULTS

There were a total of 243 cardiovascular findings detected by the standard echocardiographic examination in the 100 patients studied. Cardiac examination failed to detect 40% of the overall findings but the portable device missed only 17% of all findings. The portable device evaluated 201 conditions correctly (83%) and missed relevant clinical findings in 37 (17%) as compared to standard echocardiography, but in only 12 (5%) were these findings of major importance As an overall measure of diagnostic value, the portable device would have added to clinical judgment, thus boosting diagnostic accuracy from 62% to 83%.

CONCLUSIONS

Portable ultrasound technology can provide rapid, readily available and important clinical information for emergency physicians in the management of emergency patients with cardiomegaly.

Hand-held miniaturized cardiac ultrasound instruments for rapid and effective bedside diagnosis and patient screening

RATIONALE, AIMS AND OBJECTIVES

Technological progress in recent years has made it possible that ultrasound industry can now offer affordable, portable and battery-operated ultrasound systems the size of a laptop computer. The purpose of this study was to compare these hand-carried ultrasound instruments with standard echocardiography in order to investigate the facility of a rapid bedside diagnosis in patients with suspected or known cardiovascular disease.

METHODS

Fifty consecutive patients were studied with miniaturized ultrasound equipment (SonoHeart) and a conventional scanner (Acuson Sequoia) in a blinded manner. All studies were performed by three board-certified cardiologists skilled and experienced in echocardiographic practice. Investigators were not aware of any previous medical reports.

RESULTS

With the new system, adequate images could be obtained in all patients. Left ventricular and left atrial diameters measured with the hand-held system correlated well with those obtained with conventional scanning: r = 0.87, mean difference 3.12 +/- 2.7 mm and r = 0.84, mean difference 2.8 + 2.4 mm, respectively. The presence of left ventricular dysfunction, regional wall motion abnormalities, relevant valvular regurgitation (moderate or more) or valve stenosis was correctly diagnosed in all patients. However, there was a tendency towards underestimating the extent of wall motion abnormalities particularly in patients difficult to image. Discrepancies also frequently occurred in patients with trivial or mild regurgitation, where false-positive and false-negative findings were described.

CONCLUSION

Currently available hand-held echocardiography systems can facilitate rapid bedside diagnosis and patient screening. However, this recent development in echocardiography also raises a number of questions and its actual impact on general clinical practice still remains to be evaluated.

Evaluation of a hand carried cardiac ultrasound device in an outpatient cardiology clinic

OBJECTIVE

To determine the diagnostic potential of a hand carried cardiac ultrasound (HCU) device (OptiGo, Philips Medical Systems) in a cardiology outpatient clinic and to compare the HCU diagnosis with the clinical diagnosis and diagnosis with a full featured standard echocardiography (SE) system.

METHODS

300 consecutive patients took part in the study. The HCU examination was performed by an experienced echocardiographer before patients visited the cardiologist. The echocardiographer noted whether the HCU device was able to confirm or reject the referral diagnosis, which abnormality was detected, and whether SE investigation was necessary. Physical examination by a cardiologist followed and thereafter, whenever required, a complete study with an SE was carried out. The HCU data were compared with the clinical diagnosis of the cardiologist and the SE diagnosis in a blinded manner.

RESULTS

The cardiologist referred 203 of 300 patients for an SE study and 13 patients for transoesophageal echocardiography. In 84 patients no further examination was considered necessary. HCU echocardiography was able to confirm or reject the suspected clinical diagnosis in 159 of 203 (78%) patients. In 44 of 203 (22%) patients SE Doppler was needed. Agreement between the HCU device and the SE system for the detection of major abnormalities was excellent (98%). The HCU device missed 4% of the major findings. Among the 84 patients not referred for an SE, the HCU device detected unsuspected major abnormalities missed with the physical examination in 14 (17%).

CONCLUSION

Integration of an HCU device with the physical examination augments the yield of information.

Hand-held echocardiographic examination of patients with symptoms of acute coronary syndromes in the emergency department: the 30-day outcome associated with normal left ventricular wall motion

BACKGROUND

Acute chest pain is a common complaint for patients presenting to emergency departments. Electrocardiography (ECG) results and biochemical markers have strong positive predictive value, but an equally available, inexpensive, and non-invasive test with strong negative predictive value is needed. Hand-held echocardiography (HHE) might serve this purpose. The objective of this study was to test the hypothesis that in patients with symptoms suggestive of acute coronary syndrome, non-diagnostic ECG, and normal biochemical markers, HHE-documented normal left ventricular function is not associated with a clinical diagnosis of acute myocardial ischemia or infarction, nor an ischemic event within 30 days of follow-up.

METHODS

Assessment of left ventricular systolic function was performed in 150 patients with the HHE device. The incidences of the clinical end points of death, myocardial infarction, and ischemia were determined during the 30-day follow-up period. Data analysis included evaluation of specificity, sensitivity, and positive and negative predictive values.

RESULTS

The incidence of acute myocardial infarction was 2.5% (2/78) in the normal HHE group and 20% (6/30) in the abnormal HHE group (P = .002). The incidence of either acute myocardial infarction or ischemia was 7.6% (6/78) in the normal HHE group and 14.6% (6/30) in the abnormal HHE group (P = .11). The negative predictive value of HHE was 91%.

CONCLUSIONS

These results suggest a possible role for HHE in providing additional diagnostic and prognostic information in the examination of patients with a low likelihood of myocardial ischemia or infarction and symptoms suggestive of acute coronary syndrome.

Hand-carried ultrasound performed at bedside in cardiology inpatient setting - a comparative study with comprehensive echocardiography

Background

Hand-carried ultrasound (HCU) devices have been demonstrated to improve the diagnosis of cardiac diseases over physical examination, and have the potential to broaden the versatility in ultrasound application. The role of these devices in the assessment of hospitalized patients is not completely established. In this study we sought to perform a direct comparison between bedside evaluation using HCU and comprehensive echocardiography (CE), in cardiology inpatient setting.

Methods

We studied 44 consecutive patients (mean age 54 ± 18 years, 25 men) who underwent bedside echocardiography using HCU and CE. HCU was performed by a cardiologist with level-2 training in the performance and interpretation of echocardiography, using two-dimensional imaging, color Doppler, and simple calliper measurements. CE was performed by an experienced echocardiographer (level-3 training) and considered as the gold standard.

Results

There were no significant differences in cardiac chamber dimensions and left ventricular ejection fraction determined by the two techniques. The agreement between HCU and CE for the detection of segmental wall motion abnormalities was 83% (Kappa = 0.58). There was good agreement for detecting significant mitral valve regurgitation (Kappa = 0.85), aortic regurgitation (kappa = 0.89), and tricuspid regurgitation (Kappa = 0.74). A complete evaluation of patients with stenotic and prosthetic dysfunctional valves, as well as pulmonary hypertension, was not possible using HCU due to its technical limitations in determining hemodynamic parameters.

Conclusion

Bedside evaluation using HCU is helpful for assessing cardiac chamber dimensions, left ventricular global and segmental function, and significant valvular regurgitation. However, it has limitations regarding hemodynamic assessment, an important issue in the cardiology inpatient setting.

Ultrasound stethoscopy

Miniaturization and digital techniques have resulted in the development of high-resolution, battery-powered personal ultrasound devices with excellent grey-scale and color blood flow imaging capabilities. These devices are appropriately called "ultrasound stethoscopes" and are practical to use. They extend our physical perception during a clinical examination by "seeing the invisible pathology" and allow the user to address specific clinical problems anywhere at the point-of-care. Murmurs and abnormal precordial movements can be directly related to cardiac structural, functional, and flow abnormalities. A cardiac abnormality (pericardial effusion, dilated heart, valvular disease, mass lesion) is rapidly confirmed during the clinical examination and often a specific diagnosis is made. The device can effectively assist in the initial evaluation and rapid diagnosis of potentially life-threatening conditions or in situations where quick decision-making is essential. Overall, they strengthen our clinical diagnostic accuracy and also add quantitative information. The ultrasound stethoscope allows rapid screening for left ventricular dysfunction and occult aortic abdominal aneurysm and left ventricular hypertrophy in patients with hypertension. Training may become an important issue and should focus on criteria of normalcy and identifying specific and major cardiac disorders. There is no doubt, however, that these devices will revolutionize the physical cardiac examination and diagnosis.

Rapid screening of cardiac patients with a miniaturized hand-held ultrasound imager--comparisons with physical examination and conventional two-dimensional echocardiography

BACKGROUND

Rapid screening of cardiac patients with a hand-held ultrasound imager (SonoHeart [SH]) could provide valuable clinical information.

HYPOTHESIS

Whether the use of this device yields additional information to a carefully conducted physical examination and comparable findings to those of conventional two-dimensional echocardiography (2-D) during inpatient rounds is not well established and is the subject of this study.

METHODS

In all, 100 consecutive telemetry patients underwent rapid screening with 2-D and color Doppler SH during inpatient rounds. SonoHeart findings were compared with results from conventional 2-D and physical examination conducted by an attending cardiologist.

RESULTS

All patients had interpretable images. Mean scanning time with SH was 5.0 +/- 1.2 min; 2-D and SH findings were comparable. The parameters studied included chamber sizes, left ventricular (LV) systolic function, presence of LV hypertrophy (LVH), wall motion abnormalities (WMA), pericardial effusion (PE), and valvular regurgitations. Mild to moderate valvular regurgitation and LV systolic dysfunction were reliably diagnosed by SH in a number of patients whose symptoms were unrelated to the abnormalities detected.

CONCLUSIONS

Rapid screening with SH provides accurate and valuable information that would otherwise be undetected during physical examination. Its introduction into clinical practice may redefine the initial approach to patients with cardiovascular disease.

Hand-Carried Ultrasound Improves the Bedside Cardiovascular Examination

OBJECTIVES

We assessed the clinical utility of hand-carried cardiac ultrasound (HCU) devices to assist physicians in the diagnosis of cardiovascular disease.

MATERIALS AND METHODS

We reviewed 42 articles published from 1978 to 2004.

RESULTS

The capability and simplicity of the HCU device assist physicians in the diagnosis of cardiovascular disease at the initial patients contact. HCU is particularly useful in the setting of emergency or critical care, community screening, or in remote areas with limited access to health care.

CONCLUSION

The inherent limitations of the physical examination as well as the reduced focus and training in physical diagnosis of current and recent medical school graduates has set the stage for the HCU device to modify traditional medical practices by complementing the physical examination with real-time cardiovascular imaging.

Hand-carried cardiac ultrasound as a tool to screen for important cardiovascular disease in an underserved minority health care clinic

The disparity in cardiovascular outcomes among racial and social strata may be, in part, because of delayed detection of cardiovascular disease in minority patients. The low cost and portability of hand-carried cardiac ultrasound devices may make screening of underserved patients for cardiac disease feasible. A general internist evaluated 153 patients at a clinic serving an underserved population with a hand-carried cardiac ultrasound device. A total of 27 cases of significant valvular heart disease or ventricular dysfunction were detected in 19 patients (12.4%). Detection of a major cardiac abnormality could not be predicted by cardiac risk factors, age, or chief symptom, whereas patients presenting for new or acute clinic visits were more likely to have an abnormality. The low cost and portability of hand-carried cardiac ultrasound devices may make them important tools for the early detection of cardiovascular disease in minority and underserved populations and, thereby, help to reduce disparities in cardiovascular outcomes.

Hand-held echocardiography with Doppler capability for the assessment of critically-ill patients: is it reliable?

OBJECTIVE

To evaluate the diagnostic capability of a hand-carried ultrasound device (HCU) in critically ill patients when using conventional transthoracic echocardiography (TTE) as a reference.

DESIGN

Prospective, descriptive study.

SETTING

Medical-surgical intensive care unit of a teaching hospital.

PATIENTS

All patients requiring a TTE study were eligible.

INTERVENTIONS

Each patient underwent an echocardiographic examination using a full-feature echocardiographic platform (Sonos 5500, Philips Medical Systems, Andover, MA) and a small battery-operated device (SonoHeart Elite, SonoSite, Bothell, WA). The operators (level III training in echocardiography) were randomized (HCU vs. TTE) and they independently interpreted the echocardiograms at the patient bedside.

RESULTS

During a 2-month period, 55 consecutive patients (age: 61+/-16 years, simplified acute physiology score 46+/-15, body mass index 26+/-7) were studied, 40 of them being mechanically ventilated (73%). The number of acoustic windows was comparable using HCU and TTE (2.3+/-0.8 vs. 2.4+/-0.8: P=0.24). The overall diagnostic accuracy of HCU was lower compared with conventional TTE (137/171 vs. 158/171 clinical questions solved: P=0.002), reaching 80% and 92%, respectively. Despite its spectral Doppler capability, HCU missed diagnoses that were adequately identified by TTE: elevated left ventricular pressure ( n=2), relevant valvulopathy ( n=2) and moderate ( n=4) or severe ( n=2) pulmonary hypertension. Acute management was altered by HCU and TTE findings in 27 patients (49%) and 28 patients (51%), respectively.

CONCLUSIONS

In this study, HCU had a lower diagnostic accuracy compared with conventional TTE, despite its spectral Doppler capability. Further studies are needed to validate these evolving diagnostic tools in critical care settings.

Innovations in technology for critical care medicine

This new section in Critical Care presents a selection of clinically important examples of advances in critical care health technology. This article is divided into two main areas: diagnostics and monitoring. Attention is given to how bedside echocardiography can alter the cardiovascular physical examination, and to novel imaging techniques such as virtual bronchoscopy. The monitoring section discusses recent claims of improved efficiency with telemedicine for intensive care units.

Feasibility of point-of-care echocardiography by internal medicine house staff

OBJECTIVE

To determine whether internal medicine house staff with limited training in echocardiography can use point-of-care echocardiography to make simple, clinically important diagnoses.

BACKGROUND

Availability of small, portable ultrasound devices could make point-of-care echocardiography widely available. The training required to perform point-of-care echocardiography has not been established.

METHODS

Medical house staff participated in a 3-hour point-of-care echocardiography training program. Patients scheduled for standard echocardiography as part of clinical care underwent point-of-care echocardiography within 24 hours to assess four common clinically important diagnoses. Each standard echocardiogram was interpreted twice. Agreement (kappa) was calculated between point-of-care and standard echocardiography by using standard echocardiography as the gold standard and between the two interpretations of standard echocardiography.

RESULTS

Agreement (kappa) between point-of-care echocardiography and standard echocardiography was 75% (0.51) for left ventricular dysfunction (ejection fraction <55%), 79% (0.31) for moderate or severe mitral regurgitation, 92% (0.32) for aortic valve thickening or immobility, and 98% (0.51) for moderate or large pericardial effusion. Agreement between the two interpretations of standard echocardiography was 83% (0.63) for left ventricular dysfunction, 92% (0.68) for moderate or severe mitral regurgitation, 95% (0.62) for aortic valve thickening or immobility, and 97% (0.53) for moderate or large pericardial effusion.

CONCLUSIONS

Medical house staff with limited training in echocardiography can use point-of-care echocardiography to assess left ventricular function and pericardial effusion with moderate accuracy that is lower than that of standard echocardiography. Assessment of valvular disease and other diagnoses likely requires more training and/or experience in echocardiography.

Diagnostic accuracy of new handheld echocardiography with doppler and harmonic imaging properties

BACKGROUND

The first generation of handheld echocardiography devices was evaluated with divergent results because of inherent technical limitations. New handheld devices with continuous/pulsed wave Doppler and tissue harmonic imaging were introduced recently. In this study, comparisons were drawn among standard echocardiography, invasively measured systolic pulmonary artery pressure, and these new devices.

OBJECTIVE

We sought to evaluate new handheld echocardiography and its diagnostic accuracy compared with standard echocardiography.

METHODS

Two consecutive echocardiographic examinations were performed by experienced and independent examiners using handheld and standard echocardiography. Systolic pulmonary artery pressure was measured by Swan-Ganz catheter.

RESULTS

In all, 177 (56.2%) patients had normal cardiac function; 138 (43.8%) had underlying cardiac pathology. Handheld echocardiography had an overall agreement of 94.8% and kappa of 0.89 to detect the main echocardiographic finding. Handheld echocardiography detected valve disease with an agreement of 96.7% and kappa of 0.93; global left ventricular function was assessed correctly in 85.6% of cases. Pericardial effusion was diagnosed with an agreement of 91.2%. Dyssynergy was found by handheld echocardiography with an agreement of 95.4% and kappa value of 0.88. Systolic pulmonary artery pressure measured by handheld echocardiography and Swan-Ganz catheter had a correlation of 0.97.

CONCLUSION

This study demonstrates the high diagnostic accuracy of handheld devices with continuous/pulsed wave Doppler and harmonic imaging, and that these devices broaden the diagnostic spectrum while allowing for enhanced mobility in everyday clinical applications.

Intérêt de l’échocardiographe portatif Optigo en période postopératoire de chirurgie coronarienne

INTRODUCTION

After all the advances in electronic miniaturization, first hand-held echocardiographs have finally appeared in echocardiographic laboratories. However, questions still remain about their usefulness in our everyday practice and also about their good diagnosis accuracy. Since some of them do not offer modes such as pulsed or continuous wave Doppler, nor M-mode, they cannot compete with conventional devices. However, they do offer advantages such as their long autonomy, the good quality of their image as well as the one obtained with colour-Doppler mode, in addition obviously to the fact that they can be carried around very easily.

OBJECTIVES

To better define their possible uses, we assessed capabilities of one of them, the Optigo (Philips Ultrasound) to analyse patients who had undergone coronary artery bypass surgery.

METHOD

Fifty patients have been included in this study few days after the surgery. Each of the patients had two echocardiographic examinations, one with a conventional device and one with the Optigo. Two separated and blinded observers for a subsequent and side-by-side criteria comparison performed the two echocardiograms.

RESULTS

Hand-held echocardiography had a good diagnosis accuracy varying from 85% to 95% depending on the analysed criteria. It was more specifically good in the analysis of global or regional left heart function and of the right cavities as well as detecting the existence of pericardial effusion.

CONCLUSION

Hand-held echocardiographic device demonstrated high accuracy in assessing patients with recent coronary bypass surgery especially regarding cardiac function and pericardial effusion diagnosis.

Influence of hand-carried ultrasound on bedside patient treatment decisions for consultative cardiology

To test the hypothesis that hand-carried ultrasound (HCU) may influence patient treatment on consultative cardiology rounds, 235 patients who were hospitalized (aged 65 +/- 10 years) were studied. First, routine treatment decisions regarding diagnostic workup and therapy were made from patient history, physical examination, 12-lead electrocardiogram, and chart data. Second, a goal-directed HCU study was performed in <10 minutes focusing on left ventricular global and regional function, wall thickness, and presence of pericardial effusion, followed by a reassessment of treatment decisions. HCU data influenced treatment decisions in 149 patients (63%); 50% had a change in medical therapy and 22% had a change in their diagnostic workup (most with changes in both). In all, 12 patients (5%) had an immediate change in the decision for cardiac catheterization or pericardiocentesis. Overall agreement for the above findings with subsequent full-size system echocardiography ranged from 92% to 100% (kappa 0.91-0.96). Goal-directed HCU has the potential to influence bedside patient treatment decisions and expedite health care.

Screening for left ventricular dysfunction using a hand-carried cardiac ultrasound device

BACKGROUND

The hand-carried cardiac ultrasound (HCU) device is a recently introduced imaging device, which may be potentially useful in the primary care setting.

AIM

To test the screening potential of a HCU for the detection of left ventricular (LV) dysfunction by evaluating LV ejection fraction (LVEF) and inferior vena cava (IVC) collapse. Standard echocardiographic system (SE) and plasma brain natriuretic peptide (BNP) measurements were used as a reference.

METHODS

Eighty-eight consecutive patients (56 male, aged 59+/-12 years) with suspected LV dysfunction were enrolled in the study. The HCU-LVEF was visually estimated and the SE-LVEF was derived by the Simpson's biplane method. A LVEF <40% represented LV dysfunction. An IVC collapse of <50% and BNP levels > or =15 pmol/l were considered abnormal. The correlation of HCU-LVEF, HCU-IVC and BNP to the SE-LVEF and SE-IVC was analysed independently using 2x2 tables.

RESULTS

Six patients were excluded because of poor echo images. 19/82 patients had LV dysfunction. The HCU and BNP could identify 17 and 18 out of these 19 patients, respectively. The agreement for LVEF and IVC collapse between SE and HCU was 96% for both parameters. The sensitivity of IVC collapse, HCU-LVEF and BNP in identifying patients with LV dysfunction was 26, 89 and 94%, respectively.

CONCLUSION

A HCU device can reliably be used as a screening tool for LV dysfunction.

Will a handheld ultrasound scanner be applicable for screening for heart abnormalities in newborns and children?

BACKGROUND

There is significant interest in opportunities to provide echocardiography services for detection of congenital heart disease with portable, or even handheld, devices in remote areas or third world countries where conventional ultrasound systems may not be available. We tested a handheld system (HHS) (SonoHeart, SonoSite Inc, Bothell, Wash) equipped with a broadband, 7- to 4-MHz, miniaturized, curved, linear-array transducer and implemented with an improved directional Doppler flow map.

METHODS

All echocardiography scanning was performed in the neonatal nursery, pediatric intensive care department, or pediatric echocardiography laboratory of our institution. We reviewed limited echocardiography view sequences sequentially obtained by the same expert examiner (D.J.S.) in 50 infants and children (age: 1 day to 6 years), with preoperative or postoperative forms of congenital heart disease. Each patient was studied twice, once with a conventional full-feature system (FFS) and then a limited scan with the HHS using similar frequency transducers. The cardiologist (D.J.S.) and blinded research laboratory reviewers (X.L., G.K.M., R.A.R.) read the FFS and HHS image sequences for diagnosis and for grading the quality of the anatomic and flow feature images. The studies were performed and reviewed with the examiner and reviewers blinded to patient diagnosis.

RESULTS

The major diagnoses (eg, patent ductus arteriosus, atrio-ventricular (AV) canal, peripheral pulmonary valve stenosis, aortic coarctation, atrial septal defect, ventricular septal defect, preoperative or postoperative tetralogy of Fallot, and mitral regurgitation) were made by both readers, who were unaware of each other's diagnosis results. Furthermore, the average composite HHS cardiac anatomic feature score on a scale of 0 (not visualized) to 3 (visualized precisely) from the parasternal long-axis and 4- or 5-chamber view for cardiac anatomy were 2.67 +/- 0.49 (SD) and 2.50 +/- 0.55, respectively, versus 2.73 +/- 0.45 and 2.55 +/- 0.54 for the FFS. The mean flow feature score, comprising all views, was 2.67 +/- 0.45 (HHS) versus 2.72 +/- 0.48 (FFS). The P values for all above comparisons were >.05. Image quality of the FFS anatomic structures were, thus, not statistically different from the HHS. Although the color cosmetic was different for the HHS directional (nonvelocity) map, only 9% of 150 total findings (including structural abnormalities and flow features, none of which were critical) were missed, whereas the other 91% regurgitant, shunt, stenosis flow features or heart structure were imaged adequately by the HHS in this population.

CONCLUSIONS

Implementing high-frequency transducers and programs optimized for tissue and flow imaging on the HHS should provide images of sufficient quality for targeted echocardiography examinations to determine the presence, absence, or status of congenital heart disease in newborns and young children.

Portable spectral Doppler echocardiographic device: overcoming limitations

BACKGROUND

There is evidence that new portable echocardiographic devices are useful in evaluating heart anatomy and function, but a lack of Doppler modes has up to now been an important limitation in obtaining haemodynamic data.

OBJECTIVES

To report the Doppler capabilities of a new hand held echocardiographic device.

DESIGN

Blinded comparison of two types of echocardiography machine.

SETTING

Tertiary care centre.

PATIENTS

98 consecutive patients were randomly imaged with the hand held device, with a standard platform as reference.

OUTCOME MEASURES

Pulsed wave transmitral Doppler inflow tract velocities, deceleration time, and continuous wave Doppler measurements of aortic ejection and tricuspid regurgitation peak velocities were recorded.

RESULTS

There was excellent agreement between the hand held device and standard echocardiography for the evaluation of diastolic E and A waves, E/A ratio, and deceleration time with pulsed wave Doppler (intraclass correlation coefficients of 0.97, 0.93, 0.90, and 0.78, respectively). In addition, good agreement was found between continuous wave Doppler measurements of aortic ejection and tricuspid regurgitation velocities (intraclass correlation coefficients of 0.96 and 0.80). However, there was a significant difference between patients with tricuspid regurgitation measured with the hand held device (25.5%) and by standard echocardiography (65.3%), resulting in misdiagnosis of eight patients with pronounced pulmonary hypertension.

CONCLUSIONS

New hand held devices with Doppler capabilities overcome previous limitations in evaluating haemodynamic variables. With colour Doppler they are now suitable for the complete evaluation of valvar disease and diastolic function. However, important limitations remain in the evaluation of pulmonary pressures.

Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service

OBJECTIVE

We sought to determine whether physicians with training in echocardiography could successfully use a small echocardiographic device to detect occult cardiovascular disease in patients admitted to a general medical service.

METHODS

In all, 103 consecutive patients had a physician-performed bedside echocardiographic examination with a small portable ultrasound device.

RESULTS

Of patients, 70% did not have a clinical indication for echocardiography and of these patients, 39% had an abnormal study with the portable ultrasound device. There was a high rate of false-positive examinations, but approximately 17% of patients without a clinical indication for echocardiography had an important cardiac abnormality detected, including 10% with unsuspected left ventricular systolic dysfunction.

CONCLUSIONS

Many patients on a general medical hospital ward have unsuspected, clinically important cardiac findings such as left ventricular dysfunction that can be screened for by physicians with training in echocardiography using small portable ultrasound devices.

[Usefulness of hand-held echocardiography in emergency room]

BACKGROUND AND OBJECTIVE

Handheld echocardiography may be a powerful diagnostic tool in the emergency room. However, its usefulness in this environment when it is performed by medical personnel with a basic training in echocardiography remains to be clarified.

PATIENTS AND METHOD

A cardiologist with expertise in echocardiography and a cardiology fellow with basic training evaluated 33 patients admitted in emergency using a handheld device.

RESULTS

The echocardiogram led to a change in the diagnosis and treatment in 27% and 46% of patients, respectively, allowing an early discharge in 49% of cases. The agreement between the two observers was acceptable.

CONCLUSIONS

Portable echocardiography is a useful tool in emergency rooms and may be reliably performed by medical personnel with basic training in echocardiography.

Accuracy of hand-carried ultrasound

Hand-carried ultrasound introduces a new group of devices, operators and usage patterns to echocardiography. This may have significant impact on the accuracy of the findings obtained with hand-carried ultrasound. Although reasonable agreement can be obtained with standard echocardiography in certain circumstances, limitations in imaging modes, device image quality, operator experience, and study completeness may significantly limit the diagnostic accuracy of hand carried ultrasound. Despite this, hand-carried ultrasound has the potential to improve significantly upon the data obtained by physical examination.

Utility of hand-carried ultrasound for consultative cardiology

Although the stethoscope has been an important part of the bedside cardiac diagnostic examination for generations of physicians, this clinical tool has been relatively unchanged in over 150 years. Echocardiography is established as an essential diagnostic imaging method for patients with known or suspected cardiovascular diseases. However, routine echocardiography systems are large and heavy, and although they are portable, they remain inconvenient for bedside patient rounds. Technologic advances have resulted in miniaturization of electronic components and small, lightweight ultrasound systems have been recently introduced. These hand-carried units offer clinically acceptable two-dimensional image quality for rapid "quick-look" bedside diagnostics, in particular focusing on global and regional left ventricular function and presence or absence of pericardial effusion. This article proposes a general approach to the rapid hand-carried ultrasound cardiac exam as an extension of the physical examination. It details case examples and reviews the initial clinical experience of hand-carried ultrasound on cardiac consultation rounds. Hand-carried ultrasound has promise to have an immediate impact on bedside patient management though expediting and facilitating the delivery of medical care.

The hand-carried echocardiographic device as an aid to the physical examination

Physical examination skills have been declining over the past several decades while technology has made diagnostic testing increasingly sophisticated. For patients with cardiovascular disease, the best approach to bedside diagnosis would be one that combines both physical examination and ready access to technology at the time of the patient encounter. Most cardiac testing is not performed at the bedside due to equipment size and time limitations for these tests. Small hand-carried echocardiographic devices are now available for rapid bedside examination. These devices compare well to full-featured systems when used in cardiology outpatient settings and in hospitalized patients who are not critically ill. Compared with physical examination by board certified cardiologists, these devices decrease diagnostic error. Early use of hand-carried echocardiographic devices after physical examination has been demonstrated to impact patient triage and treatment as well as uncover otherwise undetected cardiac disease. The degree of training required for responsible use of these devices is as yet unclear. However, organized training sessions have resulted in modest agreement with standard echocardiography and point-of-care echocardiography performed by expert echocardiographers. It is conceivable that the hand-carried echocardiographic devices will be used in medical school curriculum to enhance medical student education in the future.

Hand carried echocardiography in the critical care setting

Miniaturized echocardiography units known as hand carried ultrasound (HCU) now exist with features similar to those used for standard echocardiography. The small size and low cost of these units may lead to increased availability of echocardiography to be performed by all physicians taking care of critically ill patients. Use of HCU by critical care physicians may allow for improved bedside diagnosis with improved accuracy over physical examination. Studies comparing HCU with standard echocardiography in the critical care setting have reported that HCU is limited by decreased image quality and that it may miss important diagnoses even when used by experienced sonographers and echocardiographers. Despite its limitations, however, HCU can often answer important clinical questions in the critically ill. This review explores the current literature on the use of HCU in the critical care setting, discusses the limitations of HCU, and examines the costs of implementing this new technology.

The prognostic value of the physical examination in patients with chronic heart failure

The importance placed on the physical examination in the assessment of patients with cardiovascular disorders appears to be declining, perhaps in part due to a paucity of data showing its value in the modern era. To determine whether the physical examination provides important prognostic information in patients with chronic heart failure, the authors performed a post-hoc analysis of 2479 participants from the Studies of Left Ventricular Dysfunction (SOLVD) treatment trial. The presence of elevated jugular venous pressure and a third heart sound at baseline were each associated with subsequent heart failure hospitalization, the composite end point of death or heart failure hospitalization, and pump-failure death, independently of many other markers of disease severity. The subgroup of patients with at least one of these two physical examination findings was at increased risk for all-cause mortality. The authors believe that additional studies assessing the prognostic value of the physical examination should be conducted and, if favorable, likely would lead to a renewed interest in the physical examination.

[Comparison of echocardiographic studies made with new portable devices to conventional studies]

OBJECTIVES

The latest development in echocardiography is the hand-held ultrasound device. Previous studies have shown that portable ultrasound devices detect major cardiovascular pathology better than the physical examination, but their diagnostic accuracy is still not known. The purpose of this study was to compare the results of examinations made with portable devices to those obtained with higher-scale platforms.

PATIENTS AND METHOD

211 consecutive unselected patients were included in the study. Patients were randomly studied with a portable device and a standard platform (considered the gold standard for comparison) by cardiologists experienced in echocardiography. Parameters of cardiac morphology and function, and valvular regurgitation were compared and analyzed using the McNemar paired test. Differences of more than one grade were considered major differences.

RESULTS

The subjective assessment of the studies made with the portable device was significantly worse. The correlation between estimates of left ventricular function (differences not statistically significant) was adequate, but significant differences were detected in the evaluation of left atrial enlargement, left ventricular hypertrophy, aortic root enlargement, and mitral and tricuspid regurgitation.

CONCLUSIONS

Hand-held cardiac ultrasound devices do not satisfy criteria for a complete echocardiographic study. They provide accurate information about ventricular function but fail to adequately measure cardiac chambers or assess valve function.

Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction

PURPOSE

To determine the independent prognostic value of a third heart sound (S(3)) and elevated jugular venous pressure in patients with asymptomatic left ventricular dysfunction.

METHODS

We performed a post hoc analysis of 4102 participants from the Studies of Left Ventricular Dysfunction (SOLVD) prevention trial. In that trial, participants with asymptomatic or minimally symptomatic left ventricular dysfunction (New York Association class I or II, left ventricular ejection fraction < or =0.35, no treatment for heart failure) were allocated randomly to enalapril or placebo and followed for a mean (+/- SD) of 34 +/- 14 months. The presence of an S(3) and elevated jugular venous pressure was ascertained by physical examination at study enrollment. We used multivariate proportional hazards models to determine whether these physical examination findings were associated with the development of heart failure, a prespecified endpoint of the SOLVD prevention trial.

RESULTS

At baseline, 209 subjects (5.1%) had an S(3) and 70 (1.7%) had elevated jugular venous pressure. Heart failure developed in 1044 subjects (25.5%). After adjusting for other markers of disease severity, an S(3) was associated with an increased risk of heart failure (relative risk [RR] = 1.38; 95% confidence interval [CI]: 1.09 to 1.73; P = 0.007) and the composite endpoint of death or development of heart failure (RR = 1.34; 95% CI: 1.09 to 1.64; P = 0.005). Elevated jugular venous pressure was also associated with these outcomes in multivariate models.

CONCLUSION

The physical examination provides prognostic information among patients with asymptomatic or minimally symptomatic left ventricular dysfunction.

Diagnostic ability of hand-held echocardiography in ventilated critically ill patients

STUDY OBJECTIVES

To compare the diagnostic capability of recently available hand-held echocardiography (HHE) and of conventional transthoracic echocardiography (TTE) used as a gold standard in critically ill patients under mechanical ventilation.

DESIGN

A prospective and descriptive study.

SETTING

The general intensive care unit of a teaching hospital.

PATIENTS

All mechanically ventilated patients requiring a TTE study with a full-feature echocardiographic platform (Sonos 5500; Philips Medical Systems, Andover, MA, USA) also underwent an echocardiographic examination using a small battery-operated device (33 x 23 cm2, 3.5 kg) (Optigo; Philips Medical Systems).

INTERVENTIONS

Each examination was performed independently by two intensivists experienced in echocardiography and was interpreted online. For each patient, the TTE videotape was reviewed by a cardiologist experienced in echocardiography and the final interpretation was used as a reference diagnosis.

RESULTS

During the study period, 106 TTE procedures were performed in 103 consecutive patients (age, 59 +/- 18 years; Simplified Acute Physiology Score, 46 +/- 14; body mass index, 26 +/- 9 kg/m2; positive end-expiratory pressure, 8 +/- 4 cmH2O). The number of acoustic windows was comparable using HHE and TTE (233/318 versus 238/318, P = 0.72). HHE had a lower overall diagnostic capacity than TTE (199/251 versus 223/251 clinical questions solved, P = 0.005), mainly due to its lack of spectral Doppler capability. In contrast, diagnostic capacity based on two-dimensional imaging was comparable for both approaches (129/155 versus 135/155 clinical questions solved, P = 0.4). In addition, HHE and TTE had a similar therapeutic impact in 45 and 47 patients, respectively (44% versus 46%, P = 0.9).

CONCLUSIONS

HHE appears to have a narrower diagnostic field when compared with conventional TTE, but promises to accurately identify diagnoses based on two-dimensional imaging in ventilated critically ill patients.

Ecocardiograma portátil: ¿qué añade a la valoración cardiovascular inicial?

INTRODUCTION AND OBJECTIVES

Hand-held echocardiographic devices have recently become available. Our objective was to determine, on the basis of clinical data and basic diagnostic techniques, whether hand-held devices offer additional information useful not provided by the initial cardiovascular diagnosis.

PATIENTS AND METHOD

We prospectively studied the presence and severity (absent, mild, significative) of 7 frequent heart diseases (aortic or mitral stenosis-regurgitation, tricuspid regurgitation, and left ventricular systolic dysfunction-hypertrophy) in 36 consecutive patients (50% men; mean age 68 12 years) with 3 different methods: clinical examination and basic complementary exams, hand-held echocardiography with 2D and color Doppler imaging (OptiGo, Philips Medical Systems, The Netherlands) and a standard, last-generation transthoracic echocardiogram (Sonos 550, Philips Medical Systems, The Netherlands). We compared the results obtained with the first two methods, and combined the results of both to compare these findings against the results obtained with standard electrocardiography. Percentage agreement and Somer's D, a measure of association between ordinal variables, were calculated.

RESULTS

The hand-held device obtained better results than clinical examination (agreement 87 vs. 65%; D = 0.79 0.04 vs. 0.19 0.53) and identified severe lesions that were classified incorrectly by clinical examination in 39% (14/36) patients. However, in 8 patients (10 evaluations) it misclassified severe lesions.

CONCLUSIONS

In experienced hands, a hand-held echocardiographic device offers additional information not obtained from an initial cardiovascular diagnosis for common cardiovascular disorders, but it is no substitute for complete echocardiographic examination.