Visually estimated left ventricular ejection fraction by echocardiography is closely correlated with formal quantitative methods

Machine Learning-Enabled Fully Automated Assessment of Left Ventricular Volume, Ejection Fraction and Strain: Experience in Pediatric and Young Adult Echocardiography

BACKGROUND

Left ventricular (LV) volumes, ejection fraction (EF), and myocardial strain have been shown to be predictive of clinical and subclinical heart disease. Automation of LV functional assessment overcomes difficult technical challenges and complexities. We sought to assess whether a fully automated assessment of LV function could be reliably used in children and young adults.

METHODS

Fifty normal volunteers (22/28, female/male) were prospectively recruited for research echocardiography. LV volumes, EF, and strain were measured both manually and automatically. An experienced sonographer performed all the manual analysis and recorded the analysis timing. The fully automated analyses were accomplished by 5 groups of observers with different knowledge and medical background. AutoLV and AutoSTRAIN (TomTec) were employed for the fully automated LV analysis. The LV volumes, EF, strain, and analysis time were compared between manual and automated methods, and among the 5 groups of observers.

RESULTS

Software-determined endocardial border detection was achievable in all subjects. The analysis times of the experienced sonographer were significantly shorter for AutoLV and AutoSTRAIN than manual analyses (both p < 0.001). Strong correlations were seen between conventional EF and AutoLV (r = 0.8373), and between conventional three view global longitudinal strain (GLS) and AutoSTRAIN (r = 0.9766). The volumes from AutoLV and three view GLS from AutoSTRAIN had strong correlations among different observers regardless of level of expertise. EF from AutoLV analysis had moderately strong correlations among different observers.

CONCLUSION

Automated pediatric LV analysis is feasible in normal hearts. Machine learning-enabled image analysis saves time and produces results that are comparable to traditional methods.

Intraoperative Assessment of Noninvasive Left Ventricular Myocardial Work Indices in Patients Undergoing Aortic Valve Replacement

OBJECTIVE

Evaluation of noninvasive left ventricular (LV) myocardial work (MW) enables insights into cardiac contractility and efficacy beyond conventional echocardiography. However, there is limited intraoperative data on patients undergoing surgical aortic valve replacement (AVR). The aim of this study was to describe the feasibility and the intraoperative course of this technique of ventricular function assessment in these patients and compare it to conventional two (2D)- and three-dimensional (3D) echocardiographic measurements and strain analysis.

DESIGN

Prospective observational study.

SETTING

Single university hospital.

PARTICIPANTS

Twenty-five patients scheduled for isolated AVR with preoperative preserved left and right ventricular function, sinus rhythm, without significant other heart valve disease or pulmonary hypertension, and an uneventful intraoperative course.

INTERVENTIONS

Transesophageal echocardiography was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Evaluation was performed in stable hemodynamics, in sinus rhythm or atrial pacing and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min.

MEASUREMENTS AND MAIN RESULTS

EchoPAC v206 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D and 3D LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). Estimation of myocardial work was feasible in all patients. Although there was no significant difference in the values of 2D and 3D EF, GWI and GCW decreased significantly after AVR (T1 v T2, 1,647 ± 380 mmHg% v 1,021 ± 233 mmHg%, p < 0.001; T1 v T2, 2,095 ± 433 mmHg% v 1,402 ± 242 mmHg%, p < 0.001, respectively), while GWW remained unchanged (T1 v T2, 296 mmHg% [IQR 178-452) v 309 mmHg% [IQR 255-438), p = 0.97). This resulted in a decreased GWE directly after bypass (T1 v T2, 84% ± 6% v 78% ± 5%, p < 0.001), but GWE already improved at the end of surgery (T2 v T3, 78% ± 5% v 81% ± 5%, p = 0.003). There was no significant change in the values of GWI, GCW, or 2D and 3D LVEF before and after sternal closure (T2 v T3).

CONCLUSION

LV MW analysis showed a reduction of LV workload after bypass in our group of patients, which was not detected by conventional echocardiographic measures. This evolving technique provides deeper insights into cardiac energetics and efficiency in the perioperative course of aortic valve replacement surgery.

Hemodynamic profile of cirrhotic patients with sepsis and septic shock: A propensity score matched case-control study

PURPOSE

Our understanding of hemodynamics in cirrhotic patients with sepsis remains limited. Our study aims to investigate differences in hemodynamic profiles using echocardiography between septic patients with and without cirrhosis.

MATERIALS AND METHODS

This is a single-center, retrospective study of septic patients with echocardiogram within 3 days of ICU admission. We compared baseline characteristics, echocardiographic markers of LV systolic function arterial load between patients with and without cirrhosis. A propensity score-matched case-control model was developed to describe the differences in those echocardiography derived parameters between the groups.

RESULTS

3151 patients with sepsis were included of which 422 (13%) had cirrhosis. In the propensity score matched group with 828 patients, cirrhotic patients had significantly higher left ventricular ejection fraction (64 vs.56%, p < 0.001) and stroke volume (72 vs.48 ml, p < 0.001) along with lower arterial elastance (Ea) (1.35 1vs.20.3, p < 0.001) and systemic vascular resistance (SVR) (851 vs.1209 dynes/s/m-5, p = 0.001). The left ventricular elastance (Ees) (2.83 vs 2.45, p = 0.002) was higher and ventricular-arterial coupling (Ea/Ees) (0.48 vs. 0.86, p < 0.001) lower in cirrhotic compared to non-cirrhotic.

CONCLUSIONS

Septic patients with cirrhosis had higher LVEF with lower Ea and SVR with higher Ees and significantly lower Ea/Ees suggesting vasodilation as the principal driver of the hyperdynamic profile in cirrhosis.

Comparative analysis of late gadolinium enhancement assessment techniques for monitoring fibrotic changes in myocarditis follow-up

OBJECTIVES

To compare the repeatability and interrelation of various late gadolinium enhancement (LGE) assessment techniques for monitoring fibrotic changes in myocarditis follow-up.

MATERIALS AND METHODS

LGE extent change between baseline and 3-month cardiovascular magnetic resonance (CMR) was compared in patients with acute myocarditis using the full width at half maximum (FWHM), gray-scale thresholds at 5 and 6 standard deviations (SD5 and SD6), visual assessment with threshold (VAT) and full manual (FM) techniques. In addition, visual presence score (VPS), visual transmurality score (VTS), and a simplified visual change score (VCS) were assessed. Intraclass-correlation (ICC) was used to evaluate repeatability, and methods were compared using Spearman's correlation.

RESULTS

Forty-seven patients (38 male, median age: 27 [IQR: 21; 38] years) were included. LGE extent change differed among quantitative techniques (p < 0.01), with variability in the proportion of patients showing LGE change during follow-up (FWHM: 62%, SD5: 74%, SD6: 66%, VAT: 43%, FM: 60%, VPS: 53%, VTS: 77%, VCS: 89%). Repeatability was highest with FWHM (ICC: 0.97) and lowest with SD5 (ICC: 0.89). Semiquantitative scoring had slightly lower values (VPS ICC: 0.81; VTS ICC: 0.71). VCS repeatability was excellent (ICC: 0.93). VPS and VTS correlated with quantitative techniques, while VCS was positively associated with VPS, VTS, VAT, and FM, but not with FWHM, SD5, and SD6.

CONCLUSION

FWHM offers the least observer-dependent LGE follow-up after myocarditis. VPS, VTS, and VCS are practical alternatives, showing reliable correlations with quantitative methods. Classification of patients exhibiting either stable or changing LGE relies on the assessment technique.

CLINICAL RELEVANCE STATEMENT

This study shows that LGE monitoring in myocarditis is technique-dependent; the FWHM method yields the most consistent fibrotic tracking results, with scoring-based techniques as reliable alternatives.

KEY POINTS

Recognition of fibrotic changes during myocarditis follow-up is significantly influenced by the choice of the quantification technique employed. The FWHM technique ensures highly repeatable tracking of myocarditis-related LGE changes. Segment-based visual scoring and the simplified visual change score offer practical, reproducible alternatives in resource-limited settings.

Cardiac point-of-care ultrasound: Practical integration in the pediatric and neonatal intensive care settings

Cardiac point-of-care ultrasound (POCUS) is a technology increasingly leveraged at the bedside by pediatric critical care and neonatology providers to identify real-time hemodynamic pathophysiology. We present a framework for (1) identifying the scope of cardiac POCUS within the clinical practice setting, (2) standardizing views for protocolized hemodynamic assessment relevant to pediatric critical illness and (3) integrating POCUS findings for therapeutic guidance. Within the review, we also discuss practical strengths and limitations to image acquisition and interpretation within the varied cardiac POCUS views. Finally, we explore unique considerations within the neonatal population.    Conclusion: Cardiac POCUS is a technology and tool that reveals important real-time information at the bedside of the critically ill child and infant. Understanding strengths and limitations of cardiac POCUS views and protocolizing an approach to answer focused clinical questions provides a framework for training and translation to clinical care. What is Known: • Ultrasound technology is now ubiquitous among pediatric critical care and neonatology settings, and growing literature supports an expanded role in not only procedural but also diagnostic applications. • Cardiac POCUS influences provider perception of pathophysiology and changes clinical management. What is New: • Effective cardiac POCUS training and subsequent translation to clinical practice should improve when clinical questions and protocolized approaches to image acquisition are standardized within a specialty. • Cardiac POCUS views have strengths and limitations which must be recognized when assessing the hemodynamic profile of a child or neonate.

Use of point-of-care ultrasound to assess the severity of scorpion stings in hospitalized patients

INTRODUCTION

Scorpionism is a public health problem, especially in tropical regions. In Brazil, the prevalence of envenomation by scorpions is high, and the average national lethality is around 0.16 percent. The Tityus serrulatus scorpion is the primary species of medical importance. However, objective tools to predict and define the severity of these envenomations are lacking.

MATERIALS AND METHODS

This was an observational study conducted among patients aged 0-19 years with scorpionism. Patients were admitted to a reference hospital between December 2020 and May 2022. Point-of-care ultrasound was performed within 24 hours of the scorpion sting.

RESULTS

Forty-nine patients were included, with a median age of 3.6 (interquartile range 2.3-5.3) years and a predominance of females (51 percent). Fifteen patients (30.6 percent) presented major life-threatening signs, 32 (65.3 percent) minor systemic manifestations, and two (4.1 percent) only local manifestations. Left ventricular dysfunction was identified in 13 patients (26.5 percent). Ten patients (20.4 percent) presented pattern B (visualization of three or more B lines in the evaluated quadrant) in at least one lung window. The sensitivity and specificity of cardiac and pulmonary ultrasound to identify the most severely ill patients were 86 percent and 94 percent, respectively.

DISCUSSION

The changes found on point-of-care ultrasound were associated with life-threatening signs. All patients with class III envenomation were referred to the intensive care unit, showing the importance of early identification of this subgroup. The main limitations were the small sample size and the fact that admission to intensive care was not based on systematic criteria.

CONCLUSIONS

Point-of-care ultrasound is able to identify early signs of pulmonary congestion and heart failure in scorpionism. It can be useful for the objective selection of patients who are at a higher risk of complications and death and who require intensive support; it may also be valuable for periodic reassessments. Point-of-care ultrasound is a valuable tool for identifying and monitoring severe cases of scorpionism.

Accuracy of visual estimation of ejection fraction in patients with heart failure using augmented reality glasses

OBJECTIVE

Left ventricular ejection fraction (LVEF) is measured to assess haemodynamic status and cardiac function. It may be difficult to accurately measure in patients with heart failure (HF) as they are often poorly echogenic. The augmented reality (AR) technology is expected to provide real-time guidance that will enable more accurate measurements.

METHODS

A prospective, randomised, case-crossover simulation study was conducted to confirm the effect of AR glasses on echocardiographic interpretation in patients with HF. 22 emergency physicians participated. The participants were randomly assigned to two groups. Group A estimated the visual ejection fraction of echocardiographic video clips without the AR glasses, while group B estimated them with glasses. After a washout period, the two groups crossed over. The estimates were then compared with the ejection fraction measurements obtained by echocardiologists; intraclass correlation coefficient (ICC) was calculated.

RESULTS

The ICC with glasses (0.969, 95% CI 0.966 to 0.971) was higher than without glasses (0.705, 95% CI 0.681 to 0.727) among all participants. In the subgroup analysis, the first-year and second-year residents showed the most significant difference, with an ICC of 0.568 (95% CI 0.508 to 0.621) without glasses compared with 0.963 (95% CI 0.958 to 0.968) with glasses. For the third-year and fourth-year residents group, the ICC was 0.754 (95% CI 0.720 to 0.784) without glasses and 0.972 (95% CI 0.958 to 0.968) with glasses. Among the group of attending physicians, the ICC was 0.807 (95% CI 0.775 to 0.834) without glasses and 0.973 (95% CI 0.969 to 0.977) with glasses.

CONCLUSIONS

AR glasses could be helpful in measuring LVEF and could be more helpful to those with little visual estimation experience.

Diastology in the intensive care unit: Challenges for the assessment and future directions

Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.

Empowering Medical Students: Harnessing Artificial Intelligence for Precision Point-of-Care Echocardiography Assessment of Left Ventricular Ejection Fraction

Introduction

Point-of-care ultrasound (POCUS) use is now universal among nonexperts. Artificial intelligence (AI) is currently employed by nonexperts in various imaging modalities to assist in diagnosis and decision making.

Aim

To evaluate the diagnostic accuracy of POCUS, operated by medical students with the assistance of an AI-based tool for assessing the left ventricular ejection fraction (LVEF) of patients admitted to a cardiology department.

Methods

Eight students underwent a 6-hour didactic and hands-on training session. Participants used a hand-held ultrasound device (HUD) equipped with an AI-based tool for the automatic evaluation of LVEF. The clips were assessed for LVEF by three methods: visually by the students, by students + the AI-based tool, and by the cardiologists. All LVEF measurements were compared to formal echocardiography completed within 24 hours and were evaluated for LVEF using the Simpson method and eyeballing assessment by expert echocardiographers.

Results

The study included 88 patients (aged 58.3 ± 16.3 years). The AI-based tool measurement was unsuccessful in 6 cases. Comparing LVEF reported by students' visual evaluation and students + AI vs. cardiologists revealed a correlation of 0.51 and 0.83, respectively. Comparing these three evaluation methods with the echocardiographers revealed a moderate/substantial agreement for the students + AI and cardiologists but only a fair agreement for the students' visual evaluation.

Conclusion

Medical students' utilization of an AI-based tool with a HUD for LVEF assessment achieved a level of accuracy similar to that of cardiologists. Furthermore, the use of AI by the students achieved moderate to substantial inter-rater reliability with expert echocardiographers' evaluation.

Association between self-reported alcohol consumption and diastolic dysfunction: a cross-sectional study

BACKGROUND AND OBJECTIVES

While alcohol consumption is associated with common risk factors for diastolic dysfunction the independent impact of low levels of alcohol consumption on this condition in a community setting is still unclear.Thus, the aim of this study was to explore this association in a representative population sample employing optimal echocardiographic techniques.

DESIGN

Cross-sectional observational study in community-based population.

SETTINGS, PARTICIPANTS AND METHODS

Participants between 30 and 75 years of age were consecutively invited to a physical examination, interview, conventional echocardiography, including Tissue Velocity Imaging. Diastolic dysfunction was defined according to the European Society of Cardiology criteria, excluding subjects with ejection fraction <45%, self-reported history of heart failure or atrial fibrillation on ECG. Self-reported alcohol intake using a validated questionnaire was categorised as no intake, low and medium-high intake.

RESULTS

In total, 500 men and 538 women (mean age 55.4±13) were successfully examined. Diastolic dysfunction was identified in 16% (79/500) of the men and 13% (58/538) of the women. The multivariable adjusted model revealed a strong and independent association between alcohol intake and diastolic dysfunction. In fact, using no alcohol intake as reference, diastolic dysfunction was independently associated with alcohol consumption in a dose-dependent fashion; low consumption, OR 2.3 (95% CI 1.3 to 4.0) and medium-high consumption OR 3.1 (95% CI 1.6 to 6.2), respectively.

CONCLUSION

There was a significant association between alcohol consumption and diastolic dysfunction starting already at low levels that was supported by a dose-dependent pattern. These results need confirmatory studies and are important in public health policies.

Echocardiographic hemodynamic assessment in decompensated cirrhosis: comparison between Intensivists and Gastroenterologists

BACKGROUND & AIMS

Ascites is a frequent complication of cirrhosis. In intensive care units, initial hemodynamic assessment is frequently performed by echocardiography. This study evaluated the feasibility and usefulness of early hemodynamic assessment in the gastroenterology ward.

METHODS

This observational cohort study prospectively included all patients admitted to a teaching hospital's gastroenterology unit for decompensated cirrhosis. A gastroenterologist with minimal training and an intensivist both performed an echocardiography exam. The primary outcome was inter-rater agreement and reliability for three echocardiography parameters: visual LVEF (Left Ventricular Ejection Fraction), subaortic VTI (velocity time integral) and E wave velocity. Secondary outcomes were agreement for presence of pleural effusion, description of 3 hemodynamics profiles (hypovolemic, hyperkinetic and intermediate), and 28-day mortality.

RESULTS

From March 2018 to March 2020, 53 patients were included. The median age was 62 years and 81% were men. Patients presented mostly advanced liver disease, with 43% Child-Pugh C and median MELD score of 15.2. The limits of agreement between intensivists and gastroenterologists for subaortic VTI were - 6.6 to 7.2 cm, and ranged from - 0.6 to 0.37 m.s-1 for E wave velocity. Clinically significant differences between intensivists and gastroenterologists were found in 22% for subaortic VTI and 24.5% for E wave velocity. Reliability was good for subaortic VTI (ICC: 0.79, 95% CI [0.58; 0.9;]) and moderate for E wave velocity (0.53, 95% CI [0.19; 0.74]). The three hemodynamics profiles had different prognosis, with a 28-day mortality for Hypovolemic, Intermediate and Hyperkinetic group of 31, 18, and 4%, respectively.

CONCLUSION

Reliability of hemodynamic assessment by gastroenterologists was good, while agreement was unsatisfactory, advocating for further training. Transthoracic echocardiography can differentiate hypovolemia from hyperkinetic states. The role of transthoracic echocardiography in managing decompensated cirrhosis requires further study.

CLINICAL TRIAL NUMBER

NCT03650660.

Implementing an interprofessional point-of-care ultrasound protocol for dyspneic patients in an emergency department as a blended learning concept-Feasibility of Employing Thoracic Ultrasound in Shortness of Breath

Objective

Dyspnea is a common symptom in the Emergency Department, with a wide variety of differential diagnoses. Previous research has demonstrated the diagnostic accuracy of Point-of-Care Ultrasound (POCUS) in this field of interest. Our goal was to better establish sonography in our emergency department with a practicable and time effective method. Therefore, we implemented a sonography protocol in an interprofessional emergency team using blended learning as a modern didactic approach and evaluated the learning and teaching success. We named the study FETUS, which stands for "Feasibility of Employing Thoracic Ultrasound in Shortness of Breath."

Methods

A demonstration of the POCUS protocol was given, followed by individual supervision during clinical routine. A written manual, a pocket card, and further materials for personal training supplemented the training. A post-training questionnaire measured several parameters regarding the training, e.g., subjective skill-acquisition or media use.

Results

32 medical and nursing staff participated in this study, 14 of whom completed the questionnaire. All training modalities offered were well received. A pre-post comparison of subjective sonographic competence shows a significant increase in both medical and nursing staff.The other items surveyed also indicate the success of the intervention undertaken.

Conclusion

The use of different media as a blended learning approach can support the implementation of new measures in the ongoing working routine within an interprofessional team.

Comparison of visual estimation and quantitative measurement of left ventricular ejection fraction in untrained perioperative echocardiographers

BACKGROUND

Perioperative evaluation of the left ventricular systolic function is essential information to help diagnose and manage life-threatening perioperative emergencies. Although quantifying the left ventricular ejection fraction (LVEF) is recommended to determine the left ventricular function, it may not always be feasible in emergency perioperative settings. This study compared the visual estimation of LVEF (eyeballing) by noncardiac anesthesiologists with the quantitative LVEF measured using a modified Simpson's biplane method.

METHODS

Transesophageal echocardiographic (TEE) studies of 35 patients were selected and 3 different echocardiographic views (the mid-esophageal four chamber view, the mid-esophageal two chamber view, and the transgastric mid-papillary short axis view) were recovered from each study and displayed in random order. Two cardiac anesthesiologists certified in perioperative echocardiography independently measured LVEF using the modified Simpson method and categorized LVEF into five grades: hyperdynamic LVEF, normal, mildly reduced LVEF, moderately reduced LVEF and severely reduced LVEF. Seven noncardiac anesthesiologists with limited experience in echocardiography also reviewed the same TEE studies and estimated the LVEF and graded LV function. The precision of the LV function classification and the correlation between visual estimation of LVEF and quantitative LVEF were calculated. The agreement of measurements between the two methods was also assessed.

RESULTS

Pearson's correlation between the LVEF estimated by the participants and the quantitative LVEF using the modified Simpson method was 0.818 (p < 0.001). Of a total of 245 responses, 120 (49.0%) responses were correct grading of the LV function. Participants were able to classify the LV function more accurately in the LV function grades 1 and 5 (65.3%). The 95% level of agreement of the Bland-Altman method was - 11.3-24.5. -21.9-22.6, - 23.1-26.5, - 20.5-22.0 and - 26.6-11.1 for LV grade 1 to 5, respectively.

CONCLUSION

Visual estimation of LVEF in perioperative TEE has acceptable accuracy in untrained echocardiographers and can be used for rescue TEE.

Quantification of left ventricular ejection fraction and cardiac output using a novel semi-automated echocardiographic method: a prospective observational study in coronary artery bypass patients

BACKGROUND

Echocardiographic quantification of ejection fraction (EF) by manual endocardial tracing requires training, is time-consuming and potentially user-dependent, whereas determination of cardiac output by pulmonary artery catheterization (PAC) is invasive and carries a risk of complications. Recently, a novel software for semi-automated EF and CO assessment (AutoEF) using transthoracic echocardiography (TTE) has been introduced. We hypothesized that AutoEF would provide EF values different from those obtained by the modified Simpson's method in transoesophageal echocardiography (TOE) and that AutoEF CO measurements would not agree with those obtained via VTI_LVOT in TOE and by thermodilution using PAC.

METHODS

In 167 patients undergoing coronary artery bypass graft surgery (CABG), TTE cine loops of apical 4- and 2-chamber views were recorded after anaesthesia induction under steady-state conditions. Subsequently, TOE was performed following a standardized protocol, and CO was determined by thermodilution. EF and CO were assessed by TTE AutoEF as well as TOE, using the modified Simpson's method, and Doppler measurements via velocity time integral in the LV outflow tract (VTI_LVOT). We determined Pearson's correlation coefficients r and carried out Bland-Altman analyses. The primary endpoints were differences in EF and CO. The secondary endpoints were differences in left ventricular volumes at end diastole (LVEDV) and end systole (LVESV).

RESULTS

AutoEF and the modified Simpson's method in TOE showed moderate EF correlation (r = 0.38, p < 0.01) with a bias of -12.6% (95% limits of agreement (95%LOA): -36.6 - 11.3%). AutoEF CO correlated poorly both with VTI_LVOT in TOE (r = 0.19, p < 0.01) and thermodilution (r = 0.28, p < 0.01). The CO bias between AutoEF and VTI_LVOT was 1.33 l min^-1 (95%LOA: -1.72 - 4.38 l min^-1) and 1.39 l min^-1 (95%LOA -1.34 - 4.12 l min^-1) between AutoEF and thermodilution, respectively. AutoEF yielded both significantly lower EF (EF_AutoEF: 42.0% (IQR 29.0 - 55.0%) vs. EF_{TOE Simpson}: 55.2% (IQR 40.1 - 70.3%), p < 0.01) and CO values than the reference methods (CO_{AutoEF biplane}: 2.30 l min^-1 (IQR 1.30 - 3.30 l min^-1) vs. CO_{VTI LVOT}: 3.64 l min^-1 (IQR 2.05 - 5.23 l min^-1) and CO_PAC: 3.90 l min^-1 (IQR 2.30 - 5.50 l min^-1), p < 0.01)).

CONCLUSIONS

AutoEF correlated moderately with TOE EF determined by the modified Simpson's method but poorly both with VTI_LVOT and thermodilution CO. A systematic bias was detected overestimating LV volumes and underestimating both EF and CO compared to the reference methods.

TRIAL REGISTRATION

German Register for Clinical Trials (DRKS-ID DRKS00010666, date of registration: 08/07/2016).

Intraoperative Noninvasive Left Ventricular Myocardial Work Indices in Patients Undergoing On-Pump Coronary Artery Bypass Surgery

OBJECTIVES

Noninvasive echocardiographic analysis of left ventricular (LV) myocardial work (MW) enables insights into cardiac mechanics, contractility, and efficacy beyond ejection fraction (EF) and global longitudinal strain (GLS). However, there are limited perioperative data on patients undergoing coronary artery bypass graft (CABG) surgery. The authors aimed to describe the feasibility and the intraoperative course of this novel assessment tool of ventricular function in these patients, and compare it to conventional 2-dimensional (2D) and 3-dimensional (3D) echocardiographic parameters and strain analysis.

DESIGN

A prospective observational study.

SETTING

At a single university hospital.

PARTICIPANTS

Twenty-five patients with preoperative preserved LV and right ventricular function, sinus rhythm, without significant heart valve disease or pulmonary hypertension, and an uncomplicated intraoperative course scheduled for isolated on-pump CABG surgery.

INTERVENTIONS

Transesophageal echocardiography (TEE) was performed intraoperatively after the induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). All measurements were performed under stable hemodynamic conditions, in sinus rhythm or atrial pacing, and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min.

MEASUREMENTS AND MAIN RESULTS

The EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D and 3D LVEF, LV GLS, LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). The MW analysis was feasible in all patients. Although there was no significant difference in the values of 2D and 3D EF during the intraoperative interval, GLS deteriorated significantly after CABG compared to assessment after induction of anesthesia (T1 v T2, -13.3 ± 3.0% v -11.6 ± 3.1%; p = 0.012). The GWI declined significantly after surgery (T1 v T2, 1,224 ± 312 mmHg% v 940 ± 267 mmHg%; p < 0.001), as well as GCW (T1 v T2, 1,460 ± 312 mmHg% v 1,244 ± 336 mmHg%; p = 0.005). The GWW increased after CABG (T1 v T2, 143 mmHg% (IQR 99-183) v 251 mmHg% (IQR 179-361); p < 0.001), and GWE decreased (T1 v T2, 89% (IQR 85-92) v 80% (IQR 75-87); p < 0.001). There were no significant changes in the values of 2D and 3D EF, GLS, GWI, GCW, GWW, and GWE before and after sternal closure (T2 v T3).

CONCLUSION

The intraoperative analysis of noninvasive echocardiographically-assessed LV MW indices is feasible. In the short-term period after uncomplicated on-pump CABG, GLS, as well as global and constructive MW, decreased, whereas wasted work increased, resulting in a less efficient left ventricle. None of these aspects was detected by conventional echocardiographic parameters. Therefore, strain and MW analysis might be more sensitive parameters in detecting myocardial dysfunction by TEE in the perioperative setting, adding information on perioperative cardiac energetics.

Echocardiographic Characteristics and Clinical Outcomes of the Hyperdynamic Heart: A 'Super-Normal' Heart is not a Normal Heart

A hyperdynamic heart is defined as a left ventricular (LV) with an ejection fraction (EF) above the normal range. Is this favorable? We looked at the diastolic properties of subjects with a hyperdynamic heart and its impact on outcome. Consecutive echocardiography examinations during 5 years were evaluated by EF subgroups, including a hyperdynamic heart (EF >70%). All examinations with significant LV hypertrophy or valve disease were excluded. The study included 16,994 subjects. A total of 720 subjects (4.2%) had a hyperdynamic heart. Subjects with a hyperdynamic heart were older, more likely to be women, and more likely to have hypertension, diabetes, and obesity. A total of 20% of patients had a diagnosis of heart failure. This group had a higher heart rate, smaller ventricular size, and the highest relative wall thickness. All indexes of diastolic dysfunction were significantly more prevalent in the hyperdynamic group. This included a higher LV mass, larger left atrial volume, reduced relaxation (smaller mitral e'), longer deceleration time, and higher LV end-diastolic pressures (high mitral E/e' ratio) and peak tricuspid regurgitation gradient. Diastolic dysfunction, defined by an abnormal functional or structural parameter, was present in 78% of the subjects. Survival was significantly lower in the group with a hyperdynamic heart. The Cox regression analysis after adjustment demonstrated reduced survival during a median 9-year follow-up in the hyperdynamic group compared with those with a normal EF (hazard ratio 1.56, 95% confidence interval 1.38 to 1.76, p <0.001). In conclusion, subjects with a hyperdynamic systolic function have increased prevalence of diastolic dysfunction and reduced survival. A hyperdynamic heart is not a normally functioning heart.

Clinician's guide to trustworthy and responsible artificial intelligence in cardiovascular imaging

A growing number of artificial intelligence (AI)-based systems are being proposed and developed in cardiology, driven by the increasing need to deal with the vast amount of clinical and imaging data with the ultimate aim of advancing patient care, diagnosis and prognostication. However, there is a critical gap between the development and clinical deployment of AI tools. A key consideration for implementing AI tools into real-life clinical practice is their "trustworthiness" by end-users. Namely, we must ensure that AI systems can be trusted and adopted by all parties involved, including clinicians and patients. Here we provide a summary of the concepts involved in developing a "trustworthy AI system." We describe the main risks of AI applications and potential mitigation techniques for the wider application of these promising techniques in the context of cardiovascular imaging. Finally, we show why trustworthy AI concepts are important governing forces of AI development.

Cardiac and vascular effects of low-dose steroids during the early phase of septic shock: An echocardiographic study

Background

Low-dose steroids are known to increase arterial pressure during septic shock through restoration of vasopressor response to norepinephrine. However, their effects on cardiac performance and ventriculo-arterial coupling (VAC) have never been scrutinized during human septic shock. The aim of this study was to perform a comprehensive description of the cardiovascular effects of low-dose steroids using modern echocardiographic tools (including speckle tracking imaging).

Methods

This prospective study was conducted in the intensive care unit (ICU) of a university hospital in France. Consecutive adult patients admitted for septic shock and requiring low-dose steroid therapy were prospectively enrolled within 24 h of septic shock onset. We recorded hemodynamic and echocardiographic data to explore left ventricle (LV) contractility, loading conditions and VAC just before the initiation of low-dose steroids (50 mg intravenous hydrocortisone plus 50 μg enteral fludrocortisone) and 2–4 h after.

Results

Fifty patients [65 (55–73) years; 33 men] were enrolled. Arterial pressure, heart rate, almost all LV afterload parameters, and most cardiac contractility parameters significantly improved after steroids. VAC improved with steroid therapy and less patients had uncoupled VAC (&gt; 1.36) after (24%) than before (44%) treatment.

Conclusion

In this comprehensive echocardiographic study, we confirmed an improvement of LV afterload after initiation of low-dose steroids. We also observed an increase in LV contractility with improved cardiovascular efficiency (less uncoupling with decreased VAC).

Advanced Echocardiographic Techniques in Cardio-Oncology: the Role for Early Detection of Cardiotoxicity

PURPOSE OF REVIEW

Implementation of advanced echocardiographic techniques in cardio-oncology is a growing need as they are the cornerstone of early detection of cancer therapy-related cardiovascular toxicity (CTR-CVT).

RECENT FINDINGS

Three-dimensional echocardiography and myocardial deformation techniques have shown more accuracy and reproducibility than classic 2D measurements in detecting cardiovascular adverse effects in patients undergoing anticancer therapies. Application of advanced echo techniques to daily monitoring of patients with cancer helps to identify those at risk of developing CTR-CVT during and after cancer treatment. Furthermore, advanced echo parameters improve early initiation of cardioprotective treatments in order to minimize cardiovascular events and cancer treatment interruption.

Advanced Echocardiography Techniques: The Future Stethoscope of Systemic Diseases

Cardiovascular disease (CVD) has been showing patterns of extensive rise in prevalence in the contemporary era, affecting the quality of life of millions of people and leading the causes of death worldwide. It has been a provocative challenge for modern medicine to diagnose CVD in its crib, owing to its etiological factors being attributed to a large array of systemic diseases, as well as its non-binary hideous nature that gradually leads to functional disability. Novel echocardiography techniques have enabled the cardiac ultrasound to provide a comprehensive analysis of the heart in an objective, feasible, time- and cost-effective manner. Speckle tracking echocardiography, contrast echocardiography, and 3D echocardiography have shown the highest potential for widespread use. The uses of novel modalities have been elaborately demonstrated in this study as a proof of concept that echocardiography has a place in routine general practice with supportive evidence being as recent as its role in the concurrent COVID-19 pandemic. Despite such evidence, many uses remain off-label and unexploited in practice. Generalization of echocardiography at the point of care can become a much-needed turning point in the clinical approach to case management. To actualize such aspirations, we recommend further prospective and interventional studies to examine the effect of implementing advanced techniques at the point of care on the decision-making process and evaluate their effectiveness in prevention of cardiovascular morbidities and mortalities.

Hyperdynamic Left Ventricular Ejection Fraction in ICU Patients With Sepsis

OBJECTIVES

To evaluate the cause and prognosis of hyperdynamic left ventricular ejection fraction in critically ill patients with sepsis.

DESIGN

Retrospective, single-center cohort study.

SETTING

University Hospital ICU, Birmingham, United Kingdom.

PATIENTS

ICU patients who received a transthoracic echocardiogram within 7 days of sepsis between April 2016 and December 2019.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The 90-day mortality rates of normal (55-70%), depressed (< 55%), and hyperdynamic left ventricular ejection fraction (> 70%) were compared. Multivariate logistic regression analysis was performed to determine the association of left ventricular ejection fraction phenotypes with mortality and the association of clinical variables with left ventricular ejection fraction phenotypes. One thousand fourteen patients met inclusion criteria and were 62 years old (interquartile range, 47-72), with mostly respiratory infections (n = 557; 54.9%). Ninety-day mortality was 32.1% (n = 325). Patients with hyperdynamic left ventricular ejection fraction had a higher mortality than depressed and normal left ventricular ejection fraction cohorts (58.9% [n = 103] vs 34.0% [n = 55] vs 24.7% [n = 167]; p < 0.0001, respectively). After multivariate logistic regression, hyperdynamic left ventricular ejection fraction was independently associated with mortality (odds ratio, 3.90 [2.09-7.40]), whereas depressed left ventricular ejection fraction did not (odds ratio, 0.62 [0.28-1.37]). Systemic vascular resistance was inversely associated with hyperdynamic left ventricular ejection fraction (odds ratio, 0.79 [0.58-0.95]), and age, frailty, and ischemic heart disease were associated with depressed left ventricular ejection fraction.

CONCLUSIONS

Hyperdynamic left ventricular ejection fraction was associated with mortality in septic ICU patients and may reflect unmitigated vasoplegia from sepsis. Depressed left ventricular ejection fraction was not associated with mortality but was associated with cardiovascular disease.

[Targeted hemodynamic monitoring in the operating theatre: what for and by what means?]

Goal directed hemodynamic monitoring and the balance in goal directed therapy between adequate fluid/volume therapy and the application of vasoactive or inotropic drugs are the basic elements of modern perioperative therapy.Surgical procedures should be accompanied by as few side effects and complications as possible. Nevertheless, the number of postoperative complications remains surprisingly high, despite of the modern surgical procedures. Anticipation of potential complications in the perioperative period and their rapid treatment build a core competence of anesthesiological action. Thus, it is clear that anesthesia plays a central role in this balancing act.This article aims to provide an overview of the application of the currently available perioperative goal directed hemodynamic monitoring. The current possibilities are discussed by using a case example and an outlook on the future of hemodynamic monitoring is given.

Acute Kidney Injury in Critically-Ill COVID-19 Patients

Purpose: Acute kidney injury (AKI) is common in patients with COVID-19, however, its mechanism is still controversial, particularly in ICU settings. Urinary proteinuria profile could be a non-invasive tool of interest to scrutinize the pathophysiological process underlying AKI in COVID-19 patients. Material and Methods: We conducted a retrospective study between March 2020 and April 2020. All patients with laboratory-confirmed COVID-19 and without end-stage kidney disease requiring renal replacement therapy before ICU admission were included. Our objectives were to assess the incidence and risk factors for AKI and to describe its clinical and biological characteristics, particularly its urinary protein profile. Results: Seventy patients were included; 87% needed mechanical ventilation and 61% needed vasopressor during their ICU stay; 64.3% of patients developed AKI and half of them needed dialysis. Total and tubular proteinuria on day 1 were higher in patients with AKI, whereas glomerular proteinuria was similar in both groups. The main risk factor for AKI was shock at admission (OR = 5.47 (1.74−17.2), p < 0.01). Mortality on day 28 was higher in AKI (23/45, 51.1%) than in no-AKI patients (1/25, 4%), p < 0.001. Risk factors for 28-days mortality were AKI with need for renal replacement therapy, non-renal SOFA score and history of congestive heart failure. Conclusions: AKI is common in COVID-19 patients hospitalized in ICU; it seems to be related to tubular lesions rather than glomerular injury and is related to shock at ICU admission.

Machine learning algorithm using publicly available echo database for simplified “visual estimation” of left ventricular ejection fraction

BACKGROUND

Left ventricular ejection fraction calculation automation typically requires complex algorithms and is dependent of optimal visualization and tracing of endocardial borders. This significantly limits usability in bedside clinical applications, where ultrasound automation is needed most.

AIM

To create a simple deep learning (DL) regression-type algorithm to visually estimate left ventricular (LV) ejection fraction (EF) from a public database of actual patient echo examinations and compare results to echocardiography laboratory EF calculations.

METHODS

A simple DL architecture previously proven to perform well on ultrasound image analysis, VGG16, was utilized as a base architecture running within a long short term memory algorithm for sequential image (video) analysis. After obtaining permission to use the Stanford EchoNet-Dynamic database, researchers randomly removed approximately 15% of the approximately 10036 echo apical 4-chamber videos for later performance testing. All database echo examinations were read as part of comprehensive echocardiography study performance and were coupled with EF, end systolic and diastolic volumes, key frames and coordinates for LV endocardial tracing in csv file. To better reflect point-of-care ultrasound (POCUS) clinical settings and time pressure, the algorithm was trained on echo video correlated with calculated ejection fraction without incorporating additional volume, measurement and coordinate data. Seventy percent of the original data was used for algorithm training and 15% for validation during training. The previously randomly separated 15% (1263 echo videos) was used for algorithm performance testing after training completion. Given the inherent variability of echo EF measurement and field standards for evaluating algorithm accuracy, mean absolute error (MAE) and root mean square error (RMSE) calculations were made on algorithm EF results compared to Echo Lab calculated EF. Bland-Atlman calculation was also performed. MAE for skilled echocardiographers has been established to range from 4% to 5%.

RESULTS

The DL algorithm visually estimated EF had a MAE of 8.08% (95%CI 7.60 to 8.55) suggesting good performance compared to highly skill humans. The RMSE was 11.98 and correlation of 0.348.

CONCLUSION

This experimental simplified DL algorithm showed promise and proved reasonably accurate at visually estimating LV EF from short real time echo video clips. Less burdensome than complex DL approaches used for EF calculation, such an approach may be more optimal for POCUS settings once improved upon by future research and development.

Evaluation of COVID-19-Associated Myocarditis Via Point-of-Care Ultrasound in a Pediatric Patient

ABSTRACT

Coronavirus disease 2019 (COVID-19)-associated myocarditis has been reported from the onset of the pandemic. The presumed etiology is direct damage to the myocardium from severe acute respiratory syndrome coronavirus 2. Common findings include electrocardiogram abnormalities, elevated cardiac markers, and diminished cardiac function. This can lead to heart failure and cardiogenic shock with resultant poor perfusion. Thus, myocarditis has been recognized as a cause of death in patients with COVID-19. Unfortunately, it is difficult to predict the prevalence of myocarditis in these patients given the relative novelty of the pandemic and the lack of available data. Point-of-care ultrasound (POCUS) has been shown to be a useful modality to investigate lung pathology in patients with COVID-19. Bedside cardiac POCUS can also be used to investigate cardiac pathology. This case describes a pediatric patient with COVID-19 who had evidence of myocarditis on POCUS in the pediatric emergency department.

A prospective observational study of electrocardiographic and echocardiographic changes in traumatic brain injury - effect of surgical decompression

BACKGROUND

Traumatic brain injury (TBI) causes significant changes in myocardial function, which is represented by ECG and echocardiographic changes. We intended to study the effect of surgical decompression on these changes.

MATERIALS AND METHODS

We recruited adult TBI patients undergoing surgery within 48 h of injury. Preoperatively, the patient's demographic and clinical details were recorded. ECG and TTE were performed before surgery and 24 h later (first postoperative day [POD1]). ECG was analyzed for heart rate, PR, QRS, and QTc intervals, morphologic end-repolarization abnormalities (MERA), and ST-segment and T wave changes. TTE data included left ventricular ejection fraction (LVEF) and regional wall motion abnormalities (RWMA). Glasgow coma scale (GCS) at discharge was recorded. ECG and TTE changes before and after surgery were compared, and its association with discharge GCS was analyzed. Preoperative predictors of LV dysfunction were analyzed.

RESULTS

Of the 110 patients recruited, common ECG changes were prolonged QTc interval (42%) and MERA (47%). TTE showed poor LVEF (<50%) in 10% and RWMA in 10.8% of patients. Following surgery, both ECG and TTE changes improved. Preoperative LVEF <50% and/or RWMA were associated with a lower GCS score at discharge. Preoperative poor GCS motor score and prolonged QTc interval were independent predictors of LV dysfunction.

CONCLUSIONS

Poor LV function was associated with poor admission GCS and prolonged QTc interval. Patients with reduced LV function had lower GCS at discharge.

The Association of Moderate Aortic Stenosis with Poor Survival is Modified by Age and Left Ventricular Function

BACKGROUND

Data on the independent association of moderate aortic stenosis (AS) with excess mortality, even when it does not progress to severe AS, is limited.

OBJECTIVE

To evaluate the association of moderate AS with poor survival and to identify clinically important modifiers of that association.

METHODS

Consecutive patients who underwent echocardiographic evaluation between 2007 and 2019. All-cause mortality and cancer data were available for all patients from national registries. Cox regression survival models were applied with censoring of patients who developed metastatic cancer, developed > moderate AS, or underwent aortic valve intervention during follow-up.

RESULTS

The study population included 92,622 patients. There were 2,202 (2%) patients with moderate AS, with a median age of 79 (IQR 70-85), of whom 1,254(57%) were men. During follow-up of 5 (IQR 3-8) years, 19,712 (21%) patients died. The cumulative probability of death at 5 years was higher for moderate AS patients (46% vs. 18% respectively, p Log-rank < .001). Propensity score matching analysis (N=2,896) that included clinical, laboratory, and echocardiographic predictors of poor survival demonstrated that compared with ≤ mild AS, patients with moderate AS were 17% more likely to die (95% CI 1.04-1.30, p = 0.007). Moreover, the model showed that the moderate AS associated risk was ejection fraction (EF) and age-dependent with a more pronounced association among non-octogenarian patients and patients with reduced EF (p for interaction .001 and .016 respectively).

CONCLUSION

Moderate AS is independently associated with excess mortality, even when it does not progress to severe AS. The associated risk is more pronounced among patients with reduced EF and patients younger than 80 years.

[Intraoperative transesophageal echocardiography for emergency diagnostics in noncardiac surgery patients]

Due to the development of compact and mobile devices, transesophageal echocardiography (TEE) is now being used as one important point-of-care diagnostic method in emergency rooms, intensive care units and operating rooms. In the first part of this advanced training series, general aspects of the examination method and the procedure as well as indications and contraindications were outlined. In addition, an overview of application areas beyond cardiac surgery in which TEE can be used to monitor the patient or to assist with the operative procedure was provided. In the second part, the main findings during intraoperative TEE in the event of hemodynamic instability or unexplained hypoxemia are presented. A shortened emergency examination as proposed by Reeves et al. is outlined. The article concludes with an outlook on semiautomatic interpretation software and computer-aided image acquisition.

Myocarditis Following mRNA COVID-19 Vaccine

ABSTRACT

A growing number of adolescents are being diagnosed with acute myocarditis following mRNA COVID-19 vaccinations. This case describes an adolescent who presented to the emergency department with chest pain and tachycardia following the Pfizer-BioNTech COVID-19 vaccination. Point-of-care ultrasound was performed prior to the return of laboratory studies and revealed depressed left ventricular systolic function. Point-of-care ultrasound may be a tool used to rapidly diagnose or risk stratify patients with potential post-COVID-19 vaccine myocarditis.

Left Ventricular Ejection Fraction Assessment by Emergency Physician-Performed Bedside Echocardiography: A Prospective Comparative Evaluation of Multiple Modalities

BACKGROUND

Although there is some support for visual estimation (VE) as an accurate method to estimate left ventricular ejection fraction (LVEF), it is also scrutinized for its subjectivity. Therefore, more objective assessments, such as fractional shortening (FS) or e-point septal separation (EPSS), may be useful in estimating LVEF among patients in the emergency department (ED).

OBJECTIVE

Our aim was to compare the real-world accuracy of VE, FS, and EPSS using a sample of point-of-care cardiac ultrasound transthoracic echocardiography (POC-TTE) images acquired by emergency physicians (EPs) with the gold standard of Simpson's method of discs, as measured by comprehensive cardiology-performed echocardiography.

METHODS

We conducted a single-site prospective observational study comparing VE, FS, and EPSS to assess LVEF. Adult patients in the ED receiving both POC-TTE and comprehensive cardiology TTE were included. EPs acquired POC-TTE images and videos that were then interpreted by 2 blinded EPs who were fellowship-trained in emergency ultrasound. EPs estimated LVEF using VE, FS, and EPSS. The primary outcome was accuracy.

RESULTS

Between April and May 2018, 125 patients were enrolled and 113 were included in the final analysis. EP1 and EP2 had a κ of 0.94 (95% confidence interval [CI] 0.87-1.00) and 0.97 (95% CI 0.91-1.00), respectively, for VE compared with gold standard, a κ of 0.40 (95% CI 0.23-0.57) and 0.38 (95% CI 0.18-0.57), respectively, for EPSS compared with gold standard, and a κ of 0.70 (95% CI 0.54-0.85) and 0.66 (95% CI 0.50-0.81), respectively, for FS compared with gold standard. Sensitivity of severe dysfunction was moderate to high in VE (EP1 85% and EP2 93%), poor to moderate in FS (EP1 73% and EP2 50%), and poor in EPSS (EP1 11% and EP2 18%).

CONCLUSIONS

Using a real-world sample of POC-TTE images, the quantitative measurements of EPSS and FS demonstrated poor accuracy in estimating LVEF, even among experienced sonographers. These methods should not be used to determine cardiac function in the ED. VE by experienced physicians demonstrated reliable accuracy for estimating LVEF compared with the gold standard of cardiology-performed TTE.

Potential role of an athlete-focused echocardiogram in sports eligibility

Sudden cardiac death (SCD) of an athlete is a rare but tragic event and sport activity might play a trigger role in athletes with underlying structural or electrical heart diseases. Preparticipation screenings (PPs) have been conceived for the potential to prevent SCD in young athletes by early identification of cardiac diseases. The European Society of Cardiology protocol for PPs includes history collection, physical examination and baseline electrocardiogram, while further examinations are reserved to individuals with abnormalities at first-line evaluation. Nevertheless, transthoracic echocardiography has been hypothesized to have a primary role in the PPs. This review aims to describe how to approach an athlete-focused echocardiogram, highlighting what is crucial to focus on for the different diseases (cardiomyopathies, valvulopathies, congenital heart disease, myocarditis and pericarditis) and when is needed to pay attention to overlap diagnostic zone ("grey zone") with the athlete's heart. Once properly tested, focused echocardiography by sports medicine physicians may become standard practice in larger screening practices, potentially available during first-line evaluation.

Perioperative Two-Dimensional Left Ventricular Global Longitudinal Strain in Coronary Artery Bypass Surgery: A Prospective Observational Pilot Study

OBJECTIVES

There are limited data on perioperative left ventricular strain. The authors aimed to describe the entire perioperative course of two-dimensional left ventricular global longitudinal strain in patients undergoing coronary artery bypass graft (CABG) surgery and compare to common parameters of LV function assessment.

DESIGN

Prospective observational study.

SETTING

Single university hospital.

PARTICIPANTS

Forty patients scheduled for isolated on-pump CABG surgery with preserved left and right ventricular function with an unremarkable, complication-free perioperative course.

INTERVENTIONS

Two-dimensional strain analysis and standard echocardiographic assessment of left ventricular function were performed pre- (T1) and postoperatively (T4) by transthoracic echocardiography (TTE) and intraoperatively pre- (T2) and poststernotomy (T3) by transesophageal echocardiography (TEE). Echocardiography was performed under stable hemodynamics and predefined fluid management, in sinus rhythm without any vasoactive support.

MEASUREMENTS AND MAIN RESULTS

Analysis of two-dimensional LV global longitudinal strain (2D-LV GLS) was performed using Tomtec 2D Cardiac Performance Analysis software. Philips QLAB 10.8 was used to analyze left ventricular ejection fraction (LV EF) and tissue velocity of the lateral mitral annulus (LV S ́). There were no significant differences (median with interquartile range [IQR]) after induction of anesthesia in values of LV EF and 2D-LV GLS (T1 v T2; 59% [IQR, 52 to 64] v 56% [IQR, 51.75 to 63] and -15.2 [IQR, -18.05 to -13.08] v -15.6 [IQR, -17.65 to -13.88]; both not significant [ns]), while LV S´ declined (T1 v T2, 7 cm/s [IQR, 5.25 to 8] v 5.25 cm/s [IQR, 4.6 to 6.83]; p < 0.001). Bland-Altman analysis for this comparison of 2D-LV GLS (T1 v T2) showed that bias was not significant between both techniques; however, there were limits of agreement. After sternotomy (T2 v T3) neither LV EF nor 2D-LV GLS or LV S´ declined. 2D-LV GLS deteriorated significantly after CABG (T1 v T4; -15.2 [IQR, -18.05 to -13.08] v -11.3 [IQR, -15.8 to -9.78]; p < 0.001). In contrast, LV EF and LV S´ did not change significantly in the perioperative interval (T1 v T4; 59% [IQR, 52 to 64] v 56% [IQR, 51.5 to 64.25] and 7 cm/s [IQR, 5.25 to 8] v 7 cm/s [IQR, 6 to 8]; both ns).

CONCLUSION

Values of 2D-LV GLS did not differ in awake, spontaneously breathing patients assessed by TTE and in anesthetized and ventilated patients with stable hemodynamics measured by TEE. 2D-LV GLS did not change after sternotomy; however, it declined significantly after on-pump CABG, while LV EF and LV S´ remained unchanged.

Visual versus fully automated assessment of left ventricular ejection fraction

Introduction

The aim of this study is to compare three different echocardiographic methods commonly used in the assessment of left ventricle (LV) ejection fraction (EF).

Methods

All patients underwent full echocardiography including LVEF assessed using M-mode, automated EF (Auto-EF), and visual estimation by two readers.

Results

We enrolled 268 patients. Auto-EF measurement was feasible in 240 (89.5%) patients. The averaged LVEF was (52% ± 12) with the visual assessment, (51% ± 11) with Auto-EF and (57% ± 13) with M-mode. Using Bland-Altman analysis, we found that the difference between the mean visual and the Auto-EF was not significant (-0.3% [-0.5803-0.0053], P = 0.054). However, the mean EF was significantly different when comparing visual versus M-mode and Auto-EF versus M-mode with the mean differences: (-2.4365 [-2.9946--1.8783], P < 0.0001) and (-2.1490 [-2.7348--1.5631], P < 0.0001) respectively. Inter-observer variability analysis of the visual EF assessment between the two readers showed that intraclass correlation coefficient was 0.953, (95% confidence interval: 0.939-0.965, P < 0.0001), with excellent correlation between the two readers: R = 0.911, P < 0.0001).

Conclusion

The two-dimensional echocardiographic methods using Biplane Auto-EF or visual assessment were significantly comparable, whereas M-mode results in an overestimation of the LVEF.

The impact of a perceptual learning module on novices' ability to visually estimate left ventricular ejection fraction by transesophageal echocardiography: a randomized controlled study

PURPOSE

Echocardiography is a difficult tool to master. Competency requires the supervised interpretation of hundreds of exams. Perceptual learning modules (PLMs) are novel learning tools that aim to speed up this learning process by enabling learners to go online and interpret numerous clinical images, followed systematically by expert feedback. We developed and tested a PLM aimed at improving novices' ability to quickly visually estimate left ventricular ejection fraction (LVEF) on transesophageal echocardiography images, a critical skill in acute care. We hypothesized that using the PLM would improve the accuracy and the speed of learners' estimations.

METHODS

Learners without echocardiography experience were randomly assigned to a group that used the 96-case PLM (n = 26) or a control group (n = 26) that did not. Both groups took a pre-test and an immediate post-test that measured the accuracy of their visual estimations during a first session. At six months, participants also completed a delayed post-test.

RESULTS

In the immediate post-test, the PLM group showed significantly better accuracy than the control group (median absolute estimation error 6.1 vs 9.0; difference 95% CI, 1.0 to 4.6; P < 0.001). Nevertheless, at six months, estimation errors were similar in both groups (median absolute estimation error 10.0 vs 10.0; difference 95% CI, -1.3 to 2.1; P = 0.27).

CONCLUSIONS

Participation in a short online PLM significantly improved novices' short-term ability to accurately estimate LVEF visually, compared with controls. The effect was not sustained at six months.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03245567); registered 7 August 2017.

Critical Care Echocardiography: A Primer for the Nephrologist

Critical care echocardiography (CCE) refers to the goal-directed use of transthoracic or transesophageal echocardiography and represents one of the most common applications of critical care ultrasound. CCE can be performed at the point of care, is easily repeated following changes in clinical status, and does not expose the patient to ionizing radiation. Nephrologists who participate in the care of patients in the intensive care unit will regularly encounter CCE as part of the decision-making and bedside management of ICU patients. The four primary indications for CCE are the characterization of shock, evaluation of preload tolerance, evaluation of volume responsiveness, and serial hemodynamic assessment to evaluate response to therapeutic interventions. This article provides an overview of the anatomical structures that are routinely assessed in basic CCE, describes how these findings are incorporated into the clinical assessment of critically ill patients, and introduces some common applications of advanced CCE.

Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension (SALVATION): A Practical Echo-guided Approach Proposal

Despite the valuable use of modern applications of perioperative ultrasound across multiple disciplines, there have been limitations to its implementation, restricting its impact on patient-based clinical outcomes. Point-of-care ultrasound evaluation of hypoxia and hypotension is an important tool to assess the underlying undifferentiated etiologies in a timely manner. However, there is a lack of consensus on the formal role of ultrasound during evaluation of perioperative hypoxia or hypotension. The previous ultrasound algorithms have adopted a complex technique that possibly ignore the pathophysiologic mechanisms underlying the conditions presenting in a similar fashion. The authors here propose a simple, sequential and focused multiorgan approach, applicable for the evaluation of perioperative hypotension and hypoxia in emergency scenarios. The authors believe this approach will enhance the care provided in the postanesthesia care unit, operating room, and intensive care unit.

Perioperative echocardiography-guided hemodynamic therapy in high-risk patients: a practical expert approach of hemodynamically focused echocardiography

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.

[Perioperative optimization using hemodynamically focused echocardiography in high-risk patients-A practice guide]

BACKGROUND

The number of high-risk patients undergoing surgery is steadily increasing. In order to maintain and, if necessary, optimize perioperative hemodynamics as well as the oxygen supply to the organs (DO₂) in this patient population, a timely assessment of cardiac function and the underlying pathophysiological causes of hemodynamic instability is essential for the anesthesiologist. A variety of hemodynamic monitoring procedures are available for this purpose; however, due to method-immanent limitations they are often not able to directly identify the underlying cause of cardiovascular impairment.

OBJECTIVE

To present a stepwise algorithm for a perioperative echocardiography-based hemodynamic optimization in noncardiac surgery high-risk patients. In this context, echocardiography on demand according to international guidelines can be performed under certain conditions (hemodynamic instability, nonresponse to hemodynamic treatment) as well as in the context of a planned intraoperative procedure, mostly as a transesophageal echocardiography.

METHODS AND RESULTS

Hemodynamically focused echocardiography as a rapidly available bedside method, enables the timely diagnosis and assessment of cardiac filling obstructions, volume status and volume response, right and left heart function, and the function of the heart valves.

CONCLUSION

Integrating all echocardiographic findings in a differentiated assessment of the patient's cardiovascular function enables a (patho)physiologically oriented and individualized hemodynamic treatment.

Diagnostic performance and optimal cut-off values of cardiac biomarkers for predicting cardiac injury in carbon monoxide poisoning

OBJECTIVE

This study aimed to compare the diagnostic performance of cardiac biomarkers and to evaluate the optimal cut-off values for echocardiographic cardiac injury prediction in patients with carbon monoxide (CO) poisoning.

METHODS

This retrospective observational cohort study included adult patients with acute CO poisoning. Patients who did not undergo transthoracic echocardiography, which was used to define patients with cardiac injury (ejection fraction <55%), were excluded. The area under the curve was used to evaluate diagnostic performance for cardiac injury prediction. Mann-Whitney U, chi-square, and Fisher exact tests were used to analyze data.

RESULTS

After excluding the 27 patients who did not undergo echocardiography, 114 patients were included in the study. Fifteen (13.2%) patients had cardiac injury. The area under the curve values for the B-type natriuretic peptide, creatine kinase-myocardial band, and troponin I were 0.711 (95% confidence interval [CI], 0.527-0.895; P=0.011), 0.766 (95% CI, 0.607-0.926; P=0.001), and 0.801 (95% CI, 0.647-0.955; P<0.001), respectively, with optimal cut-off values of 330 pg/mL, 10.1 ng/mL, and 0.455 ng/mL, respectively. The sensitivity, specificity, and positive and negative predictive values of troponin I were 67%, 91%, 53%, and 95%, respectively.

CONCLUSION

Troponin I showed the best diagnostic performance for predicting cardiac injury in patients with CO poisoning. A cut-off value of 0.455 ng/mL appeared optimal for cardiac injury prediction. However, further studies on cardiac biomarkers and other diagnostic tools in CO poisoning are needed given the low sensitivity of troponin I.

What can an echocardiographer see in briefly presented stimuli? Perceptual expertise in dynamic search

Background

Experts in medical image perception are able to detect abnormalities rapidly from medical images. This ability is likely due to enhanced pattern recognition on a global scale. However, the bulk of research in this domain has focused on static rather than dynamic images, so it remains unclear what level of information that can be extracted from these displays. This study was designed to examine the visual capabilities of echocardiographers—practitioners who provide information regarding cardiac integrity and functionality. In three experiments, echocardiographers and naïve participants completed an abnormality detection task that comprised movies presented on a range of durations, where half were abnormal. This was followed by an abnormality categorization task.

Results

Across all durations, the results showed that performance was high for detection, but less so for categorization, indicating that categorization was a more challenging task. Not surprisingly, echocardiographers outperformed naïve participants.

Conclusions

Together, this suggests that echocardiographers have a finely tuned capability for cardiac dysfunction, and a great deal of visual information can be extracted during a global assessment, within a brief glance. No relationship was evident between experience and performance which suggests that other factors such as individual differences need to be considered for future studies.

Feasibility of a 5G-Based Robot-Assisted Remote Ultrasound System for Cardiopulmonary Assessment of Patients With Coronavirus Disease 2019

Background

Traditional methods for cardiopulmonary assessment of patients with coronavirus disease 2019 (COVID-19) pose risks to both patients and examiners. This necessitates a remote examination of such patients without sacrificing information quality.

Research Question

The goal of this study was to assess the feasibility of a 5G-based robot-assisted remote ultrasound system in examining patients with COVID-19 and to establish an examination protocol for telerobotic ultrasound scanning.

Study Design and Methods

Twenty-three patients with COVID-19 were included and divided into two groups. Twelve were nonsevere cases, and 11 were severe cases. All patients underwent a 5G-based robot-assisted remote ultrasound system examination of the lungs and heart following an established protocol. Distribution characteristics and morphology of the lung and surrounding tissue lesions, left ventricular ejection fraction, ventricular area ratio, pericardial effusion, and examination-related complications were recorded. Bilateral lung lesions were evaluated by using a lung ultrasound score.

Results

The remote ultrasound system successfully and safely performed cardiopulmonary examinations of all patients. Peripheral lung lesions were clearly evaluated. Severe cases of COVID-19 had significantly more diseased regions (median [interquartile range], 6.0 [2.0-11.0] vs 1.0 [0.0-2.8]) and higher lung ultrasound scores (12.0 [4.0-24.0] vs 2.0 [0.0-4.0]) than nonsevere cases of COVID-19 (both, P < .05). One nonsevere case (8.3%; 95% CI, 1.5-35.4) and three severe cases (27.3%; 95% CI, 9.7-56.6) were complicated by pleural effusions. Four severe cases (36.4%; 95% CI, 15.2-64.6) were complicated by pericardial effusions (vs 0% of nonsevere cases, P < .05). No patients had significant examination-related complications.

Interpretation

Use of the 5G-based robot-assisted remote ultrasound system is feasible and effectively obtains ultrasound characteristics for cardiopulmonary assessment of patients with COVID-19. By following established protocols and considering medical history, clinical manifestations, and laboratory markers, this system might help to evaluate the severity of COVID-19 remotely.

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

Background

This study aimed to determine whether a focused 2-day cardiac ultrasound training course could enable physicians to obtain and interpret focused cardiac ultrasound (FCU) images from critically ill patients.

Methods

We retrospectively reviewed the FCU images submitted by the physicians who attended a 2-day FCU training courses. Three experienced trainers reviewed the images separately. They determined whether the images were assessable and scored the images on an 8-point scale. They also decided whether the physicians provided correct responses for visual estimations of the left ventricular ejection fraction (LVEF) and right ventricle (RV) dilatation and septal motion.

Results

Among the 327 physicians, 291 obtained images that were considered assessable (89%). The scores for parasternal short-axis view were lower than those obtained for other transthoracic echocardiographic views, p < 0.001. More physicians provided incorrect appraisals of LVEF than of RV dilatation and septal motion (19.9% vs. 3.1%, p < 0.001). The percentages of incorrect answers by LVEF category were as follows: 34.8% on images of LVEF < 30, 24.7% on images of LVEF 30–54, and 16.4% on images of LVEF ≥55%, p < 0.001. A logistic regression analysis showed that patients with abnormal LVEF were associated with physicians’ incorrect assessment of LVEF, with an odds ratio of 1.923 (95% confidence interval (CI):1.071–3.456, p = 0.029).

Conclusions

A large proportion of physicians could obtain and interpret FCU images from critically ill patients after a 2-day training course. However, they still scored low on the parasternal short-axis view and were more likely to make an incorrect assessment of LVEF in patients with abnormal left ventricular systolic function.

Left ventricular dysfunction in Duchenne muscular dystrophy

BACKGROUND

Duchenne muscular dystrophy is associated with progressive cardiorespiratory failure, including left ventricular dysfunction.

METHODS AND RESULTS

Males with probable or definite diagnosis of Duchenne muscular dystrophy, diagnosed between 1 January, 1982 and 31 December, 2011, were identified from the Muscular Dystrophy Surveillance Tracking and Research Network database. Two non-mutually exclusive groups were created: patients with ≥2 echocardiograms and non-invasive positive pressure ventilation-compliant patients with ≥1 recorded ejection fraction. Quantitative left ventricular dysfunction was defined as an ejection fraction <55%. Qualitative dysfunction was defined as mild, moderate, or severe. Progression of quantitative left ventricular dysfunction was modelled as a continuous time-varying outcome. Change in qualitative left ventricle function was assessed by the percentage of patients within each category at each age. Forty-one percent (n = 403) had ≥2 ejection fractions containing 998 qualitative assessments with a mean age at first echo of 10.8 ± 4.6 years, with an average first ejection fraction of 63.1 ± 12.6%. Mean age at first echo with an ejection fraction <55 was 15.2 ± 3.9 years. Thirty-five percent (140/403) were non-invasive positive pressure ventilation-compliant and had ejection fraction information. The estimated rate of decline in ejection fraction from first ejection fraction was 1.6% per year and initiation of non-invasive positive pressure ventilation did not change this rate.

CONCLUSIONS

In our cohort, we observed that left ventricle function in patients with Duchenne muscular dystrophy declined over time, independent of non-invasive positive pressure ventilation use. Future studies are needed to examine the impact of respiratory support on cardiac function.