Point-of-care echocardiography - A road to future or a step backwards

Echocardiography Does not Reduce Mortality in Sepsis: A Re-Evaluation Using the Medical Information Mart for Intensive Care IV Dataset

OBJECTIVES

Echocardiography is commonly used for hemodynamic assessment in sepsis, but data regarding its association with outcome are conflicting. The aim of this study was to evaluate the association between echocardiography and outcomes in patients with septic shock using the Medical Information Mart for Intensive Care IV database.

DESIGN

Retrospective cohort study comparing patients who did or did not undergo transthoracic echocardiography within the first 5 days of admission for the primary outcome of 28-day mortality.

SETTING

Admissions to the Beth Israel Deaconess Medical Center intensive care from 2008 to 2019.

PATIENTS

Adults 16 years old or older with septic shock requiring vasopressor support within 48 hours of admission. Readmissions and patients admitted to the coronary care unit or cardiovascular intensive care were excluded, as well as patients with ST-elevation myocardial infarction or cardiac arrest.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Echocardiography was performed in 1,515 (27%) of 5,697 eligible admissions. The primary outcome was analyzed using a marginal structural model and rolling entry matching to adjust for baseline and time-varying confounders. Patients who underwent echocardiography showed no significant difference in 28-day mortality (adjusted hazard ratio 1.09; 95% CI, 0.95-1.25; p = 0.24). This was consistent across multiple sensitivity analyses. Secondary outcomes were changes in management instituted within 4 hours of imaging. Treatment changes occurred in 493 patients (33%) compared with 431 matched controls (29%), with the most common intervention being the administration of a fluid bolus.

CONCLUSIONS

Echocardiography in sepsis was not associated with a reduction in 28-day mortality based on observational data. These findings do not negate the utility of echo in cases of diagnostic uncertainty or inadequate response to initial treatment.

Establishing a Novel Diagnostic Framework Using Handheld Point-of-Care Focused-Echocardiography (HoPE) for Acute Left-Sided Cardiac Valve Emergencies: A Bayesian Approach for Emergency Physicians in Resource-Limited Settings

Acute severe cardiac valve emergencies, such as acute severe mitral regurgitation (AMR) and acute severe aortic regurgitation (AAR), present significant challenges in terms of diagnosis and management. Handheld point-of-care ultrasound devices have emerged as potentially pivotal tools in ensuring the prompt and accurate diagnosis of these left-sided valve emergencies by emergency physicians, particularly in resource-limited settings. Despite the increased utilisation of point-of-care ultrasound by emergency physicians for the management of patients in states of acute cardiorespiratory failure, current diagnostic protocols cannot perform sufficient quantitative assessments of the left-sided cardiac valves. This review elucidates and evaluates the diagnostic utility of handheld point-of-care focused-echocardiography (HoPE) in native AMR and AAR by reviewing the relevant literature and the use of clinical case examples from the Emergency Department at Port Shepstone Regional Hospital (PSRH-ED)-a rural, resource-limited hospital located in KwaZulu-Natal, South Africa. Combining the findings of the review and clinical case illustrations, this review proceeds to synthesise a novel, Bayesian-inspired, iterative diagnostic framework that integrates HoPE into the evaluation of patients with acute cardiorespiratory failure and suspected severe left-sided valve lesions.

Echocardiography in Prone Positioned Critically Ill Patients: A Wealth of Information from a Single View

In critically ill patients, standard transthoracic echocardiography (TTE) generally does not facilitate good image quality during mechanical ventilation. We propose a prone-TTE in prone positioned patients, which allows clinicians to obtain a complete apical four-chamber (A-4-C) view. A basic cardiac assessment can be performed in order to evaluate right ventricle function and left ventricle performance, even measuring objective parameters, i.e., tricuspid annular plane systolic excursion (TAPSE); pulmonary artery systolic pressure (PAP), from the tricuspid regurgitation peak Doppler velocity; RV end-diastolic diameter and its ratio to left ventricular end-diastolic diameter; the S’ wave peak velocity with tissue Doppler imaging; the ejection fraction (EF); the mitral annular plane systolic excursion (MAPSE); diastolic function evaluation by the mitral valve; and annular Doppler velocities. Furthermore, by tilting the probe, we can obtain the apical-five-chamber (A-5-C) view, which facilitates the analysis of blood flow at the level of the output tract of the left ventricle (LVOT) and then the estimation of stroke volume. Useful applications of this technique are hemodynamic assessment, titration of fluids, vasoactive drugs therapy, and evaluation of the impact of prone positioning on right ventricle performance and right pulmonary resistances. We believe that considerable information can be drawn from a single view and hope this may be helpful to emergency and critical care clinicians whenever invasive hemodynamic monitoring tools are not available or are simply inconvenient due to clinical reasons.

Haemodynamic monitoring in acute heart failure - what you need to know

Acute heart failure (AHF) is a sudden, life-threatening condition, defined as a gradual or rapid onset of symptoms and/or signs of HF. AHF requires urgent medical attention, being the most frequent cause of unplanned hospital admission in patients above 65 years of age. AHF is associated with a 4–12% in-hospital mortality rate and a 21–35% 1-year mortality rate post-discharge. Considering the serious prognosis in AHF patients, it is very important to understand the mechanisms and haemodynamic status in an individual AHF patient, thus preventing end-organ failure and death. Haemodynamic monitoring is a serial assessment of cardiovascular function, intended to detect physiologic abnormalities at the earliest stages, determine which interventions could be most effective, and provide the basis for initiating the most appropriate therapy and evaluate its effects. Over the past decades, haemodynamic monitoring techniques have evolved greatly. Nowadays, they range from very invasive to non-invasive, from intermittent to continuous, and in terms of the provided parameters. Invasive techniques contain pulmonary artery catheterization and transpulmonary thermodilution. Minimally invasive techniques include oesophageal Doppler and noncalibrated pulse wave analysis. Non-invasive techniques contain echocardiography, bioimpedance, and bioreactance techniques as well as non-invasive pulse contour methods. Each of these techniques has specific indications and limitations. In this article, we aimed to provide a pathophysiological explanation of the physical terms and parameters used for haemodynamic monitoring in AHF and to summarize the working principles, advantages, and disadvantages of the currently used methods of haemodynamic monitoring.

Echocardiography is a good way to diagnose and monitor type 1 cardiorenal syndrome in ICU

BACKGROUND

Type one Cardiorenal syndrome (CRS) is defined by acute decompensated heart failure leading to secondary acute kidney injury. No studies evaluates the reliability of transthoracic echocardiography as an help tool for diagnosis and optimization of CRS. Therefore, the aim of this study was to assess echocardiographic parameters in patients with CRS in the Intensive Care Unit.

METHODS

We conducted an observational, prospective, single-center study in the ICU department of a general hospital. Patients admitted in the ICU and presenting with type 1 CRS were included. Transthoracic echocardiography was performed at baseline and at day end after treatment by the same trained operator for the same patients. We report various echocardiographic indices at these two timepoints.

RESULTS

27 patients were included. At baseline 96.3% of patients had signs of congestion (IVC dilation > 2 cm), 76 % had an altered S-wave (< 11.5 cm/s), 72.73% had an altered TAPSE (< 17 mm), 85.19% had an elevated RV/LV diameter ratio (> 0.6). Between baseline and D end, IVC size and, the number of patients with an elevated RV/LV diameter ratio significantly decreased. Weight decreased, whereas natriuresis significantly increased, and the amount of vasopressors support decreased. Diuresis, and S-wave velocity showed non-significant changes.

CONCLUSIONS

Main echocardiographic findings at baseline in patients with type 1 CRS consist of a right ventricular dysfunction associated an IVC dilation. We report that weight, RV/LV diameter ratio, and IVC diameter might constitute good follow-up parameters to monitor treatment response.

Unusual cause of heart failure in the young, the intracardiac mass: Diagnostic dilemmas solved by echocardiography

Primary cardiac tumor remains exceedingly rare, accounting for 0.5 cases per million of the population annually. We report a case of cardiac tumor, which was initially misdiagnosed as heart failure secondary to acute coronary syndrome. The diagnosis was revised later after routine echocardiography in the ward. A 39-year-old gentleman who presented to the emergency department with cardiac failure and ischemic changes on the electrocardiogram was initially worked-up for acute coronary syndrome. However, echocardiography was performed later in the ward to evaluate the cardiac ejection fraction, revealing a massive left atrial mass measuring 6 cm × 4 cm. Severe mitral regurgitation was noted through the echocardiogram owing to the mass prolapse into the mitral annulus. The initial presentation of cardiac tumors can be ambiguous. Studies have shown that echocardiography as the noninvasive cardiac imaging approach remains the gold standard of diagnostic tool. Hence, echocardiography should be performed as a routine assessment of cardiac failure. Meanwhile, the incorporation of point of care ultrasound in the available center may assist the physician to diagnose accurately in the emergency department setting by excluding other potential differential diagnoses. Delay in diagnosis and initiation of treatment may result in progression to chronic heart failure and dangerous complication, i.e. hemodynamic sequelae and systemic embolism of the clot. In our experience, we managed to reach an accurate diagnosis, timely referral and appropriate intervention despite the lack of point of care ultrasound.