Focused Cardiac Ultrasonography: Current Applications and Future Directions

Focused Cardiac Ultrasound to Guide the Diagnosis of Heart Failure in Pregnant Women in India

BACKGROUND

Cardiac complications are a leading cause of maternal death. Cardiac imaging with echocardiography is important for prompt diagnosis, but it is not available in many low-resource settings. The aim of this study was to determine whether focused cardiac ultrasound performed by trained obstetricians and interpreted remotely by experts can identify cardiac abnormalities in pregnant women in low-resource settings.

METHODS

A cross-sectional study was conducted among 301 pregnant and postpartum women recruited from 10 hospitals across three states in India. Twenty-two obstetricians were trained in image acquisition using a portable cardiac ultrasound device following a simplified protocol adapted from focus-assessed transthoracic echocardiography protocol. It included parasternal long-axis, parasternal short-axis, and apical four-chamber views on two-dimensional and color Doppler. Independent image interpretation was performed remotely by two experts, in the United Kingdom and India, using a standard semiquantitative assessment protocol. Interrater agreement between the experts was examined using Cohen's κ. Diagnostic accuracy of the method was examined in a subsample for whom both focused and conventional scans were available.

RESULTS

Cardiac abnormalities identified using the focused method included valvular abnormalities (27%), rheumatic heart disease (6.6%), derangements in left ventricular size (4.7%) and function (22%), atrial dilatation (19.5%), and pericardial effusion (30%). There was substantial agreement on the cardiac parameters between the two experts, ranging from 93.6% (κ = 0.84) for left ventricular ejection fraction to 100% (κ = 1) for valvular disease. Image quality was graded as good in 79% of parasternal long-axis, 77% of parasternal short-axis and 64% of apical four-chamber views. The chance-corrected κ coefficients indicated fair to moderate agreement (κ = 0.28-0.51) for the image quality parameters. There was good agreement on diagnosis between the focused method and standard echocardiography (78% agreement), compared in 36 participants.

CONCLUSIONS

The focused method accurately identified cardiac abnormalities in pregnant women and could be used for screening cardiac problems in obstetric settings.

The diagnostic capabilities of the combined cardiac and lung point of care ultrasound in shocked patients at the emergency department - Resourced limited country

Purpose

Cardiac, lung, and inferior vena cava (IVC) ultrasound are commonly performed in the care of emergency patients especially patient presented with hypotension or shock. However, the literature indicated the limitation of IVC to assess shocked patients. This study aims to determine the efficacy of combined cardiac and lung ultrasound for evaluation the etiology of shock.

Materials and Methods

A cross-sectional study was conducted on patient with shock at emergency department, Srinagarind Hospital, Thailand, from January to December 2021. Adult shocked patients who met the criteria were included in this study. Ultrasound and emergency department medical records were documented and analyzed as sensitivity, specificity, predictive value, negative predictive value, diagnostic accuracy, and Cohen's kappa coefficient (κ).

Results

One hundred and two who met the criteria were enrolled. Combined cardiac and lung scans were found to be accurate 99.02% and 93.04% in obstructive and cardiogenic shock. In patients with obstructive shock was the almost perfect agreement, (κ) = 0.85. However, distributive, and hypovolemic shock had the low concordance with the final hospital diagnosis, (κ) = 0.37 and 0.43, respectively.

Conclusions

The integration of cardiac and lung ultrasound can be effectively used to narrow differential diagnosis of shock.

The Parasternal Long Axis View in Isolation: Is it Good Enough?

BACKGROUND

Focused cardiac ultrasound (FOCUS) is a vital tool to evaluate patients at the bedside, but its use can be limited by patient habitus, sonographer skill, and time to perform the examination.

OBJECTIVE

Our primary goal was to determine the diagnostic accuracy of the parasternal long axis (PSLA) view in isolation for identifying pericardial effusion, left ventricular (LV) dysfunction, and right ventricular (RV) dilatation compared with a four-view FOCUS examination.

METHODS

This was a retrospective study looking at FOCUS images. Examinations were blinded and randomized for review by point-of-care ultrasound faculty. The primary objective was measured by comparing ultrasound findings on PSLA view in isolation with findings on a full four-view FOCUS examination, which served as the criterion standard. Sensitivity and specificity were calculated.

RESULTS

Of 100 FOCUS examinations; 36% were normal, 16% had a pericardial effusion, 41% had an LV ejection fraction < 50%, and 7% had RV dilatation. Sensitivity and specificity for identifying pericardial effusion, LV dysfunction, and RV dilatation were 81% (confidence interval [CI] 0.54-0.95) and 98% (95% CI 0.91-0.99), 100% (95% CI 0.88-1) and 91% (95% CI 0.80-0.97), and 71% (95% CI 0.30-0.94) and 99% (95% CI 0.93-1), respectively. All moderate to large effusions were identified correctly. Overall, there were only four clinically significant disagreements between PSLA alone and the four-view interpretations.

CONCLUSIONS

In isolation, the PSLA view was highly sensitive and specific for identifying LV ejection fraction and moderate to large pericardial effusions. It was highly specific for identifying RV dilatation, but had only moderate sensitivity.

Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist

Point-of-Care Ultrasound (POCUS) is a valuable bedside diagnostic tool for a variety of expeditious clinical assessments or as guidance for a multitude of acute care procedures. Varying aspects of nearly all organ systems can be evaluated using POCUS and, with the increasing availability of affordable ultrasound systems over the past decade, many now refer to POCUS as the 21^st-century stethoscope. With the current available and growing evidence for the clinical value of POCUS, its utility across the perioperative arena adds enormous benefit to clinical decision-making. Cardiothoracic anesthesiologists routinely have used portable ultrasound systems for nearly as long as the technology has been available, making POCUS applications a natural extension of existing cardiothoracic anesthesia practice. This narrative review presents a broad discussion of the utility of POCUS for the cardiothoracic anesthesiologist in varying perioperative contexts, including the preoperative clinic, the operating room (OR), intensive care unit (ICU), and others. Furthermore, POCUS-related education, competence, and certification are addressed.

Basic echocardiography competence program in intensive care units: A multinational survey of intensive care units accredited by the College of Intensive Care Medicine

In 2014, basic critical care echocardiography (BCCE) competence became a mandatory requirement for trainees registered with the College of Intensive Care Medicine (CICM). To determine the proportion of CICM intensive care units (ICUs) that conduct a BCCE competence program and to learn about the barriers/challenges and successful strategies, we conducted a survey of intensivists working in ICUs accredited by CICM for basic/advanced training in Australia, New Zealand, Hong Kong, Singapore, Ireland and India. Following consultations with content experts and a trial phase to improve clarity and minimise ambiguity, an 11-point questionnaire survey was sent to one intensivist from every CICM-accredited ICU by several methods. Participation was voluntary. Consent was implied. No incentives were offered. Results are reported as numbers and percentages. Of the 104 ICUs surveyed, 99 (95.1%) responded, with 75 (75.8%) having no BCCE teaching whatsoever. In the remaining 24 (24.2%) ICUs, the teaching process was widely variable. Only 5/99 (5.1%) ICUs provided a structured BCCE competence program through which trainees performed and archived BCCE scans, maintained a logbook and underwent formative and summative assessments for credentialling. Six more ICUs provided formative assessment but relied on external bodies for competence assessment. Overall, 20/99 (20.2%) ICUs allowed trainees to perform unsupervised scans for clinical management, even if they were not BCCE competent. Nineteen intensivists perceived management errors due to misinterpretation of echocardiographic findings. Very few CICM-accredited ICUs offer a structured BCCE competence program. To fulfil the objective of universal BCCE competence, potential solutions are presented.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.