Focus cardiac ultrasound core curriculum and core syllabus of the European Association of Cardiovascular Imaging

Focused cardiac ultrasound: Competency among pre-internship medical officers in diagnosing cardiac causes of dyspnea

BACKGROUND

Differentiating cardiovascular causes of dyspnea in resource-limited healthcare settings can be challenging. The use of easy-to-train, point-of-care, focused cardiac ultrasound (FoCUS) protocols may potentially alleviate this challenge.

RESEARCH QUESTION

Can novices attain competency in FoCUS use after training using the cardiac ultrasound for resource-limited settings (CURLS) protocol?

METHODS

A quasi-experimental study was conducted at the Kenyatta National Hospital in Nairobi, Kenya. Forty-five graduate medical pre-interns, novices in cardiac ultrasound, received simulated didactic and hands-on FoCUS skills training using the CURLS protocol and 2018 European Association of Cardiovascular Imaging (EACVI) FoCUS training and competence assessment recommendations. Competency was assessed in image interpretation, image acquisition, and image quality.

RESULTS

Aggregate image interpretation competency was attained by n = 38 (84%) of trainees with a median score of 80%. The proportion of trainees attaining category-specific image interpretation competency was as follows: pericardial effusion n = 44 (98%), left atrial enlargement n = 40 (89%), cardiomyopathy n = 38 (84%), left ventricular hypertrophy n = 37 (82%), and right ventricular enlargement n = 29 (64%). Image acquisition skills competency was attained by n = 36 (80%) of trainees. Three-quarters of trainee-obtained images were of good quality.

CONCLUSION

Majority of the trainees attained competency. Training constraints limit the generalizability of our findings.

Artificial Intelligence and Its Role in Diagnosing Heart Failure: A Narrative Review

Heart failure (HF) is prevalent globally. It is a dynamic disease with varying definitions and classifications due to multiple pathophysiologies and etiologies. The diagnosis, clinical staging, and treatment of HF become complex and subjective, impacting patient prognosis and mortality. Technological advancements, like artificial intelligence (AI), have been significant roleplays in medicine and are increasingly used in cardiovascular medicine to transform drug discovery, clinical care, risk prediction, diagnosis, and treatment. Medical and surgical interventions specific to HF patients rely significantly on early identification of HF. Hospitalization and treatment costs for HF are high, with readmissions increasing the burden. AI can help improve diagnostic accuracy by recognizing patterns and using them in multiple areas of HF management. AI has shown promise in offering early detection and precise diagnoses with the help of ECG analysis, advanced cardiac imaging, leveraging biomarkers, and cardiopulmonary stress testing. However, its challenges include data access, model interpretability, ethical concerns, and generalizability across diverse populations. Despite these ongoing efforts to refine AI models, it suggests a promising future for HF diagnosis. After applying exclusion and inclusion criteria, we searched for data available on PubMed, Google Scholar, and the Cochrane Library and found 150 relevant papers. This review focuses on AI's significant contribution to HF diagnosis in recent years, drastically altering HF treatment and outcomes.

Correlations and discrepancies between cardiac ultrasound, clinical diagnosis and the autopsy findings in early deceased patients with suspected cardiovascular emergencies

Cardiac ultrasound (CUS), either focused cardiac ultrasound (FoCUS) or emergency echocardiography, is frequently used in cardiovascular (CV) emergencies. We assessed correlations and discrepancies between CUS, clinical diagnosis and the autopsy findings in early deceased patients with suspected CV emergencies. We retrospectively analysed clinical and autopsy data of 131 consecutive patients who died within 24 h of hospital admission. The type of CUS and its findings were analysed in relation to the clinical and autopsy diagnoses. CUS was performed in 58% of patients - FoCUS in 83%, emergency echocardiography in 12%, and both types of CUS in 5% of cases. CUS was performed more frequently in patients without a history of CV disease (64 vs. 40%, p = 0.08) and when the time between admission and death was longer (6 vs. 2 h, p = 0.021). In 7% of patients, CUS was inconclusive. In 10% of patients, the ante-mortem cause of death could not be determined, while discrepancies between the clinical and post-mortem diagnosis were found in 26% of cases. In the multivariate logistic regression model, only conclusive CUS [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.30-7.39, p = 0.044] and chest pain at presentation (OR 30.19, 95%CI 5.65 -161.22, p < 0.001) were independently associated with congruent clinical and autopsy diagnosis. In a tertiary university hospital, FoCUS was used more frequently than emergency echocardiography in critically ill patients with suspected cardiac emergencies. Chest pain at presentation and a conclusive CUS were associated with concordant clinical and autopsy diagnoses.

Cardiac Output and Stroke Volume Assessments by Transthoracic Echocardiography and Pulse index Continuous Cardiac Output Monitor in Critically ill Adult Patients: A Comparative Study

PURPOSE

Bedside transthoracic echocardiography (TTEcho) is a noninvasive cardiac output (CO) monitoring method that has grown recently. However, there are questions regarding its accuracy compared to invasive methods. We aimed to evaluate the agreement and correlation of TTEcho and pulse index continuous CO (PiCCO) monitor measurements for CO and systolic volume (SV) in critically ill patients.

METHODS

This prospective experimental study included consecutive adult patients who required invasive hemodynamic monitoring admitted at an intensive care unit in the Federal District, Brazil, from January/2019 to January/2021. Correlation and agreement between SV and CO measurements by PiCCO and TTEcho were performed using the Spearman correlation and the Bland-Altman analysis.

RESULTS

The study enrolled 29 patients, with adequate TTEcho evaluations in all patients. There were very strong correlations between CO-TTEcho and CO-PiCCO (r = 0.845, P < .001) and SV-TTEcho and SV-PiCCO (r = 0.800, P < .001). TTEcho estimations for CO and SV were feasible within the limits of agreement in 96.6% (28/29) compared to PiCCO. The mean difference between CO-PiCCO and CO-TTEcho was 0.250 L/min (limits of agreement: -1.083 to 1.583 L/min, percentage error: 21.0%), and between SV-PiCCO and SV-TTEcho was 2.000 mL (limits of agreement: -16.960 to 20.960, percentage error: 24.3%). The reduced cardiac index (CI) measurements by TTEcho showed an accuracy of 89.7% (95% IC: 72.6%-97.8%) and an F1 score of 92.7% (95% IC: 75.0%-98.0%), considering the CI-PiCCO as the gold standard.

CONCLUSION

Echocardiographic measurements of CO and SV are comparable to measurements by PiCCO. These results reinforce echocardiography as a reliable tool to evaluate hemodynamics in critically ill patients.

Point-of-Care Cardiac Ultrasound Training Programme: Experience from the University Hospital Hradec Králové

Point-of-care ultrasound examinations performed by physicians of different specialties are a rapidly growing phenomenon, which has led to a worldwide effort to create a standardised approach to ultrasound examination training. The implementation of emergency echocardiography by noncardiologists is mainly aimed at the standardisation of the procedure, a structured training system, and an agreement on competencies. This article summarises the current training programmes for nonechocardiographers at the University Hospital in Hradec Králové. In cooperation with cardiologists specialised in cardiac ultrasound (ECHO), an extended acute echo protocol dedicated to emergency department physicians was developed and validated in daily practice. According to our retrospective evaluation, after one year of clinical practice, we can confirm that point-of-care ultrasound examinations performed using the standardised limited echo protocol are safe and accurate. The observed concordance with comprehensive ECHO was 78%. This trial is registered with NCT05306730.

Student survey after ten years of continuous blended teaching of echocardiography

OBJECTIVE

To analyse the impact of 10 years of blended echocardiography teaching.

METHODS AND RESULTS

A questionnaire was emailed to all medical doctors who graduated from the blended learning diploma in echocardiography developed by the University of Chile and taught by a team from Chile and Spain. One hundred and forty of the 210 students who graduated from the program between 2011 and 2020 completed the questionnaire: 53.57% were anaesthesiologists, and 26.42% were intensivists. More than 85% of respondents indicated that the online teaching met their expectations, and 70.2% indicated that the hands-on practice fulfilled the stated objectives. In a retrospective analysis using self-reported data, graduates reported that their use of transthoracic and transoesophageal echocardiography has increased from 24.29% to 40.71% and from 13.57% to 27.86%, repectively, after the programme compared to before the programme. They used echocardiography mainly in the perioperative period (56.7%) and during intensive care (32.3%), while only 11% of respondents used it in emergency care units. Nearly all (92.4%) respondents reported that the skills learned was very useful in their professional practice.

CONCLUSIONS

Ten years after its launch, the blended learning diploma in echocardiography was well rated by graduate specialists, and is associated with a significant increase in the use of echocardiography in the perioperative period and during intensive care. The main challenges are to establish a longer period of practice and achieve greater implantation in emergency medicine.

The measurement of the left ventricle ejection fraction by a bedside FoCUS examination

The use of point-of-care ultrasound is rapidly increasing in medical practice. This study aims to evaluate the left ventricle systolic function by the bedside focus cardiac ultrasound (FoCUS). We consecutively enrolled n.59 patients of the Emergency Medicine Unit of S. Andrea Hospital. Every patient received a bedside FoCUS examination to estimate the left ventricle (LV) ejection fraction (EF); the LV EF measurements were compared with those obtained by standard echocardiography (as gold standard). The LV EF obtained by the bedside FoCUS examination and the standard echocardiography, resulted, respectively: 50.2 ± 15.1% (by the Quinones equation), 39.5 + 12.0% (by the Lvivo app) and 53.7 + 11.1% (by the standard echocardiography). The correlations between the bedside FoCUS EF measurements versus standard echocardiography were statistically significant: r =  + 0.694 p < 1.9 × 10-6 (Quinones equation, Bland-Altman analysis mean = - 2.3%) and r =  + 0.571 p < 0.01 (Lvivo app, Bland-Altman analysis mean = - 13.3%). In conclusion, the present study showed a high accuracy of the bedside FoCUS EF evaluations, which may support the diagnosis of the heart failure in an emergency setting without delaying. The EF measurements by the operational method are more precise than those obtained by the unselected images of the software application.

Comparison of international guideline recommendations for the diagnosis of pulmonary embolism

Pulmonary embolism is one of the leading causes of death due to cardiovascular disease. Timely diagnosis is crucial, but challenging, as the clinical presentation of pulmonary embolism is unspecific and easily mistaken for other common medical emergencies. Clinical prediction rules and D-dimer measurement allow stratification of patients into groups of expected prevalence and are key elements in adequate selection of patients for diagnostic imaging; however, the strengths and weaknesses of the multiple proposed prediction rules, when to measure D-dimer, and which cutoff to apply might be elusive to a significant proportion of physicians. 13 international guidelines authored by medical societies or expert author groups provide recommendations on facets of the diagnostic investigations in suspected pulmonary embolism, some of which are hallmarked by pronounced heterogeneity. This Review summarises key recommendations of each guideline, considers the most recent evidence on the topic, compares guideline recommendations on each facet of the diagnosis of pulmonary embolism, and provides a synthesis on the most common recommendations.

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.

Pleural effusion and thoracentesis in ICU patients: A longitudinal observational cross-sectional study

BACKGROUND

Pleural effusion is common among patients in the intensive care unit (ICU) but reported prevalence varies. Thoracentesis may improve respiratory status, however, indications for this are unclear. We aimed to explore prevalence, development, and progression of pleural effusion, and the incidence and effects of thoracentesis in adult ICU patients.

METHODS

This is a prospective observational study utilizing repeated daily ultrasonographic assessments of pleurae bilaterally, conducted in all adult patients admitted to the four ICUs of a Danish university hospital throughout a 14-day period. The primary outcome was the proportion of patients with ultrasonographically significant pleural effusion (separation between parietal and visceral pleurae >20 mm) in either pleural cavity on any ICU day. Secondary outcomes included the proportion of patients with ultrasonographically significant pleural effusion receiving thoracentesis in ICU, and the progression of pleural effusion without drainage, among others. The protocol was published before study initiation.

RESULTS

In total, 81 patients were included of which 25 (31%) had or developed ultrasonographically significant pleural effusion. Thoracentesis was performed in 10 of these 25 patients (40%). Patients with ultrasonographically significant pleural effusion, which was not drained, had an overall decrease in estimated pleural effusion volume on subsequent days.

CONCLUSION

Pleural effusion was common in the ICU, but less than half of all patients with ultrasonographically significant pleural effusion underwent thoracentesis. Progression of pleural effusion without thoracentesis showed reduced volumes on subsequent days.

FoCUS cardiac ultrasound training for undergraduates based on current national guidelines: a prospective, controlled, single-center study on transferability

INTRODUCTION

In emergency and critical-care medicine, focused cardiac ultrasound (FoCUS) is indispensable for assessing a patient's cardiac status. The aim of this study was to establish and validate a peer-to-peer-supported ultrasound course for learning FoCUS-specific skills during undergraduate studies at a German university.

METHODS

A 1-day, 12 teaching units training course was developed for students in the clinical section of medical college, with content based on the current national guidelines. A total of 217 students participated in the study (97 in the course group and 120 in the control group). The course and the participants' subjective assessment of improved skills were evaluated using a questionnaire (7-point Likert scale; 7 = complete agreement and 1 = no agreement at all). Objective learning gains were assessed by tests before and after the course. These consisted of a test of figural intelligence (eight items) and a test of technical knowledge (13 items).

RESULTS

The course participants experienced significant improvement (P < 0.001) from before to after the course, with a large effect size of η²_part = 0.26. In addition, the course group had significantly better results (P < 0.001) than the control group in the post-test, with a medium to large effect size of η²_part = 0.14. No significant differences (P = 0.27) were detected in the test section on figural intelligence. The evaluations showed that the participants had a high degree of satisfaction with the course approach, teaching materials, and tutors. There was also a positive increase in their subjective assessment of their own skills, including areas such as technical knowledge, ultrasound anatomy, and performance of the examination.

CONCLUSION

The results of both the objective learning assessment and the subjective evaluations suggest that a FoCUS course originally intended for qualified physicians is equally suitable for students. With the development and provision of modern digital teaching media, even more students will be able to benefit from this approach in the future.

Focused cardiac ultrasound in pregnancy

Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.

The current training for non‑echocardiographers in University Hospital Hradec Králové

Emergency echocardiography is a reproducible method providing clinically significant information during the process of primary assessment of the acute cardiovascular diseases. The main aim of the course is implementation of the emergency echocardiography by non-cardiologist is the standardization of the procedure, structured training system and agreement on the competences. The article summaries the current training for non-echocardiographers in University Hospital Hradec Králové.

Point‑of‑Care Ultrasound - accuracy, education

A review article discussing the reliability of Point-of-Care ultrasound and education in this method in various fields of medicine.

A one-day focused cardiac ultrasound training has a limited impact on residents' abilities to visually assess right ventricular dimensions and function

BACKGROUND

Focused cardiac ultrasound (FCU) is a helpful tool to rapidly identify right ventricular (RV) causes of hemodynamic instability and facilitate the initiation of therapy. The clinical value of existing course models often remains unclear. This study investigated the effects of a one-day FCU training on the visual estimation skills of RV characteristics.

METHODS

Four residents were included as the study group after completing a standardized one-day FCU training. Four gender-matched controls did not take part in the training. All residents graded image quality, RV systolic function, and RV dimensions in a test comprising 35 ultrasound clips.

RESULTS

The study and control group did not differ in ICU or ultrasound experience. Overall, training participants were able to distinguish between good and insufficient image quality significantly better than the control group (agreement 80.0% vs 61.4%, p = 0.04). The agreement for the estimation of RV function and RV dimensions was not different between the groups (63.2% vs 60.5%, p = 0.66 and 64.3% vs 67.1%, p = 0.18, respectively). Descriptively, only small differences were found between the groups for the estimation of RV function and RV dimensions in subgroups of patients with normal versus reduced systolic RV function or normal versus enlarged RV dimensions, respectively. Both groups struggled in identifying RV enlargement (34.6% vs 46.2%).

DISCUSSION

In this study, a single one-day FCU training had no impact on residents' skills to visually assess systolic RV function or RV dimensions. Improvements of current training modalities or continuous teaching models are needed to optimize residency programs and patient care.

The effects of preoperative focused cardiac ultrasound in high-risk patients: A randomised controlled trial (PREOPFOCUS)

BACKGROUND

Surgery is the third most common cause of mortality worldwide. Focused cardiac ultrasound (FOCUS) yields information on cardiac status and discloses the presence of unknown pathology. Preoperative FOCUS changes patient treatment, allowing for a patient-tailored anaesthesia. We hypothesised that preoperative FOCUS would reduce the proportion of patients who were either admitted to hospital for more than 10 days or who were dead within 30 days after high-risk, non-cardiac surgery.

METHODS

This was a randomised, controlled, multi-center study. Patients ≥65 years of age, admitted for urgent orthopaedic- or abdominal surgery, scheduled for general- or neuraxial anaesthesia and with ASA 3/4 were eligible for inclusion. Patients were randomised in a 1:1 ratio to preoperative FOCUS or no preoperative FOCUS performed in accordance with a predefined protocol. Primary endpoint was the proportion of patients admitted more than 10 days or who were dead within 30 days. Secondary endpoints included major complications, days of admission and changes in anaesthesia handling.

RESULTS

During the second COVID-19 wave the study monitoring committee terminated the study prematurely. We included 338 patients of which 327 were included in the final analysis. In the FOCUS group, 41/163 (25%) patients met the criteria for the primary endpoint versus 35/164 (21%) for the control group, adjusted odds ratio 1.37 (95% CI 0.86-2.30), p = .36. The proportions of patients who developed major complications did not differ significantly between groups. Length of hospital stay was 4 (3-8) days in the FOCUS group and 4 (3-7) days on the control group (adjusted p = .24).

CONCLUSION

The routine availability of preoperative FOCUS assessment in this cohort does not appear to reduce the risk for hospitalisation exceeding 10 days or 30-day mortality, although study enrolment was prematurely terminated.

Medical student medium-term skill retention following cardiac point-of-care ultrasound training based on the American Society of Echocardiography curriculum framework

Background

No studies have demonstrated medium- or long-term skill retention of cardiac point-of-care ultrasound (POCUS) curriculum for medical student. Based on the American Society of Echocardiography (ASE) curriculum framework, we developed a blended-learning cardiac POCUS curriculum with competency evaluation. The objective of this study was to investigate the curriculum impact on image acquisition skill retention 8 weeks after initial training.

Methods

This study was a prospective, pre-post education intervention study for first- and second-year medical students, with blinded outcome assessment. The curriculum included a pre-training ASE online module and healthy volunteer hands-on training to obtain 5 views: parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical 4-chamber (A4C), subcostal 4-chamber (S4C), and subcostal inferior vena cava (SIVC) views. Students took 5-view image acquisition skill tests at pre-, immediate post-, and 8-week post-training, using a healthy volunteer. Three blinded assessors rated the image quality using a validated 10-point maximum scoring system. Students used a hand-held ultrasound probe (Butterfly iQ).

Results

Fifty-four students completed hands-on training, and pre- and immediate post-training skill tests. Twenty-seven students completed 8-week post-training skill tests. Skill test score improvement between pre- and 8-week post-training was 2.11 points (95% CI, 1.22–3.00; effect size, 1.13).

Conclusion

The cardiac POCUS curriculum demonstrated medium-term skill retention. The curriculum was sufficient for S4C and SIVC skill retention, but inadequate for PLAX, PSAX, and A4C. Therefore, instructional design modifications or re-training for PLAX, PSAX, and A4C are needed to make the curriculum more effective for clinically relevant skill retention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-022-00296-z.

Focused Cardiac Ultrasound Training for Non-cardiologists: An Overview and Recommendations for a Lower Middle-Income Country

Poor outcomes among the critically ill in low- and middle-income countries (LMICs) have been attributed in part to the challenge of diagnostic delays caused by lack of skilled personnel. Focused cardiac ultrasound (FoCUS) by non-cardiologists may mitigate the shortage of echocardiography experts to perform emergency echocardiography at the point of care in these settings. It is however crucial that FoCUS training for non-cardiologists in LMICs be based on robust evidence to support training delivery if diagnostic accuracy is to be assured.

Feasibility, diagnostic performance and clinical value of an abbreviated echocardiography protocol in an out-patient cardiovascular setting: a pilot study

Background

There has been a growing demand for echocardiography services over the last 5 years, with this supply–demand mismatch exacerbated by the COVID-19 pandemic. Prior studies have suggested a high proportion of normal findings among echocardiograms requested for patients without known cardiovascular disease, particularly in low-risk cohorts. This pilot study investigates the role of an abbreviated echocardiography protocol in improving access to echocardiography services in a low-risk outpatient setting within the rapid access chest pain (RACP) clinic.

Method

A retrospective review of electronic medical records and transthoracic echocardiography (TTE) studies for 212 patients from RACP clinic in 2019 (cohort A), prior to the introduction of the abbreviated echocardiography protocol, and 175 patients seen in the RACP clinic in 2021 (cohort B) was performed. The outcomes measured include the echocardiography referral burden from RACP clinic, waiting time for a TTE and echocardiography findings.

Results

33% and 45% of patients seen in the RACP clinic in 2019 and 2021, respectively, were referred for a TTE. The most common indications include chest pain (50%), dyspnoea (19%) and palpitations (11%). Abnormal findings were identified in 36% of TTEs performed in cohort A and 13% in cohort B. The median echocardiogram study time was significantly shorter in cohort B (7 min vs 13 min, p < 0.00001), with a lower number of images acquired (43 vs. 62, p < 0.00001). The median waiting time for an echocardiography in cohort B was significantly shorter (median: 14 days vs. 42 days in 2019, p < 0.00001). No major pathologies were missed on a retrospective review of these images.

Conclusion

Our study demonstrates that an abbreviated echocardiography protocol has potential to improve access to echocardiography services through increasing scheduling capacity, without compromising diagnostic performance in a low-risk outpatient population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44156-022-00009-2.

Point-of-care ultrasound training for residents in anaesthesia and critical care: results of a national survey comparing residents and training program directors' perspectives

BACKGROUND

Point-of-care ultrasound (POCUS) has become an essential tool for anaesthesia and critical care physicians and dedicated training is mandatory. This survey describes the current state of Italian residency training programs through the comparison of residents' and directors' perspective.

METHODS

Observational prospective cross-sectional study: 12-question national e-survey sent to Italian directors of anaesthesia and critical care residency programs (N = 40) and residents (N = 3000). Questions focused on POCUS teaching (vascular access, transthoracic echocardiography, focused assessment for trauma, transcranial Doppler, regional anaesthesia, lung and diaphragm ultrasound), organization (dedicated hours, teaching tools, mentors), perceived adequacy/importance of the training and limiting factors.

RESULTS

Five hundred seventy-one residents and 22 directors completed the survey. Bedside teaching (59.4-93.2%) and classroom lessons (29.7-54.4%) were the most frequent teaching tools. Directors reported higher participation in research projects (p < 0.05 for all techniques but focused assessment for trauma) and simulation (p < 0.05 for all techniques but transthoracic echocardiography). Use of online teaching was limited (< 10%); however, 87.4% of residents used additional web-based tools. Consultants were the most frequent mentors, with different perspectives between residents (72.0%) and directors (95.5%; p = 0.013). Residents reported self-training more frequently (48.5 vs. 9.1%; p < 0.001). Evaluation was mainly performed at the bedside; a certification was not available in most cases (< 10%). Most residents perceived POCUS techniques as extremely important. Residents underestimated the relevance given by directors to ultrasound skills in their evaluation and the minimal number of exams required to achieve basic competency. Overall, the training was considered adequate for vascular access only (62.2%). Directors mainly agreed on the need of ultrasound teaching improvement in all fields. Main limitations were the absence of a standardized curriculum for residents and limited mentors' time/expertise for directors.

CONCLUSION

POCUS education is present in Italian anaesthesia and critical care residency programs, although with potential for improvement. Significant discrepancies between residents' and directors' perspectives were identified.

Focused cardiac ultrasound examination in the emergency and critical care equine patient: Training for non-specialist veterinarians and evaluation of proficiency

Background

Focused cardiac ultrasound examination (FoCUS) is rapidly emerging for point‐of‐care cardiac assessment using hand‐carried ultrasound (HCU) devices. A specific FoCUS protocol for horses and adequate training guidelines currently are not available.

Hypothesis

To gain knowledge about the training necessary to become proficient in performing FoCUS using a HCU device.

Animals

Three healthy Warmblood horses were used for practical training of veterinarians and veterinary students in equine focused cardiac ultrasound (eFoCUS).

Methods

Prospective educational study. An eFoCUS protocol and 1‐day training course were developed. Pre‐ and post‐course written tests were administered to participants to evaluate proficiency in knowledge of echocardiography and echocardiographic pathology. A post‐course practical examination involved performing eFoCUS and storage of representative images. Images were evaluated using an image quality score and compared between participants with some practical experience and participants with no practical experience.

Results

Participants' knowledge of echocardiography increased significantly. Recognition of echocardiographic pathology pre‐course ranged from 40% to 90% (mean score, 65.7%) and post‐course from 85% to 100% (mean score, 92%). Eighteen of 21 participants were proficient in performing eFoCUS with a median image quality score of 79% (range, 42%‐95%). Image quality did not differ between participants with some practical experience compared to participants with no experience.

Conclusions and Clinical Importance

Veterinarians and veterinary students independent of previous experience can become proficient in performing eFoCUS after completion of a 1‐day training course.

Handheld ultrasound is an adjunct to the physical examination in the diagnosis of cardiopulmonary disease

Handheld 2D ultrasound devices (HUDs) have become available as an adjunct to physical examinations, visualizing the heart and lungs in real time and facilitating prompt patient diagnosis and treatment of cardiopulmonar.y disorders. These devices provide simple and rapid bedside alternatives to repetitive chest x-rays, standard ultrasound examinations and thoracic CT scans. Two currently available HUDs are described. This paper discusses the use of HUDs in the diagnosis of patients with pericardial effusion and tamponade, ventricular dilation, aortic and mitral regurgitation, cardiogenic pulmonary edema, viral and bacterial pneumonia, pleural effusion and pneumothorax. The use of a HUD by physicians increases clinical diagnostic accuracy, adds quantitative information about cardiopulmonary disease severity and guides the use of medications and interventions.

Non-Invasive Assessment of Congestion by Cardiovascular and Pulmonary Ultrasound and Biomarkers in Heart Failure

Worsening chronic heart failure (HF) is responsible for recurrent hospitalization and increased mortality risk after discharge, irrespective to the ejection fraction. Symptoms and signs of pulmonary and systemic congestion are the most common cause for hospitalization of acute decompensated HF, as a consequence of increased cardiac filling pressures. The elevated cardiac filling pressures, also called hemodynamic congestion, may precede the occurrence of clinical congestion by days or weeks. Since HF patients often have comorbidities, dyspnoea, the main symptom of HF, may be also caused by respiratory or other illnesses. Recent studies underline the importance of the diagnosis and treatment of hemodynamic congestion before HF symptoms worsen, reducing hospitalization and improving prognosis. In this paper we review the role of integrated evaluation of biomarkers and imaging technics, i.e., echocardiography and pulmonary ultrasound, for the diagnosis, prognosis and treatment of congestion in HF patients.

Lean Management Approach for Reengineering the Hospital Cardiology Consultation Process: A Report from AORN "A. Cardarelli" of Naples

Background: Consultations with specialists are essential for safe and high-quality care for all patients. Cardiology consultations, due to a progressive increase in cardiology comorbidities, are becoming more common in hospitals prior to any type of treatment. The appropriateness and correctness of the request, the waiting time for delivery and the duration of the visit are just a few of the elements that can affect the quality of the process. Methods: In this work, a Lean approach and Telemedicine are used to optimize the cardiology consultancy process provided by the Cardiology Unit of “Antonio Cardarelli” Hospital of Naples (Italy), the largest hospital in the southern Italy. Results: The application of corrective actions, with the introduction of portable devices and telemedicine, led to a reduction in the percentage of waiting for counseling from 29.6% to 18.3% and an increase in the number of patients treated. Conclusions: The peculiarity of the study is to apply an innovative methodology such as Lean Thinking in optimizing the cardiology consultancy process, currently little studied in literature, with benefits for both patients and medical staff.

Competence of anesthesiology residents following a longitudinal point-of-care ultrasound curriculum

PURPOSE

Point-of-care ultrasound (POCUS) facilitates diagnostic, procedural, and resuscitative applications in anesthesiology. Structured POCUS curricula improve learner satisfaction, test scores, and clinical management, but the learning curve towards competency and retention of skills over time remain unknown.

METHODS

We conducted a prospective observational study to determine when anesthesiology trainees enrolled in a POCUS curriculum achieve competency in POCUS skills. We also investigated the learning curve of trainees' competency using a POCUS-specific competency-based medical education assessment. The structured, longitudinal POCUS curriculum included online lectures, journal articles, live model scanning sessions, video review of cases, and a portfolio of supervised scans. Point-of-care ultrasound scanning sessions on standardized patients were conducted in the simulation lab for 2.5 hr a week and each resident completed eight sessions (20 hr) per academic year. At each scanning session, timed image acquisition scores were collected and POCUS skills entrustment scale evaluations were conducted. The primary outcome was the number of supervised scans and sessions required to achieve a mean entrustment score of 4 ("may use independently"). Secondary outcomes included image acquisition scores and retention of skills after six months.

RESULTS

The mean (standard deviation) number of supervised scans required for trainees (n = 29) to reach a mean entrustment score of ≥ 4 was 36 (10) scans over nine sessions for rescue echo. A mean entrustment score of ≥ 4 was observed for lung ultrasound after a mean (SD) of 8 (3) scans over two sessions.

CONCLUSIONS

Our study shows that anesthesiology residents can achieve competence in rescue echo and lung ultrasound through participation in a structured, longitudinal POCUS curriculum, and outlines the learning curve for progression towards competency.

Cardiac and vascular point-of-care ultrasound: current situation, problems, and future prospects

Although clinical application of ultrasound to the heart has a history of about 80 years, its big turning point was the emergence of a portable ultrasound diagnostic machine. As a result, the place, where echocardiography is performed widely spread outside the examination room, and the people who perform echocardiography have also greatly increased. Emergency physicians, anesthesiologists, and primary care physicians became interested in echocardiography and started using it. Such ultrasound examinations performed by a doctor for assessment of disease condition, management, or guidance of treatment at bedside has been called point-of-care ultrasound (POCUS). Cardiac POCUS is divided into a focused cardiac ultrasound examination (FoCUS) and limited echocardiography. The former is performed by non-experts in echocardiography, such as emergency physicians and anesthesiologists, whereas the latter is usually performed by cardiologists who are experts in echocardiography. FoCUS has an established protocol and evaluation method, and evidence to prove its effectiveness is accumulating. In addition, the COVID-19 outbreak reaffirmed the importance of POCUS. Although FoCUS is becoming popular in Japan, an educational program has not been established, and discussion on how to educate medical students and residents will be necessary. Even if POCUS in cardiovascular medicine becomes widespread, auscultation will still be necessary. Rather, adding cardiac and vascular POCUS to inspection, palpation, and auscultation in the flow of physical examinations will benefit patients greatly.

[Focus ultrasound for cardiology practice. Russian consensus document]

This document is a consensus document of Russian Specialists in Heart Failure, Russian Society of Cardiology, Russian Association of Specialists in Ultrasound Diagnostics in Medicine and Russian Society for the Prevention of Noncommunicable Diseases. In the document a definition of focus ultrasound is stated and discussed when it can be used in cardiology practice in Russian Federation.

Echocardiography in the intensive care unit: An essential tool for diagnosis, monitoring and guiding clinical decision-making

In the last years, new trends on patient diagnosis for admission in cardiac intensive care unit (CICU) have been observed, shifting from acute myocardial infarction or acute heart failure to non-cardiac diseases such as sepsis, acute respiratory failure or acute kidney injury. Moreover, thanks to the advances in scientific knowledge and higher availability, there has been increasing use of positive pressure mechanical ventilation which has its implications on the heart. Therefore, there is a growing need for Cardiac intensivists to quickly, noninvasively and repeatedly evaluate various hemodynamic conditions and the response to therapy. Transthoracic critical care echocardiography (CCE) currently represents an essential tool in CICU, as it is used to evaluate biventricular function and complications following acute coronary syndromes, identify the mechanisms of circulatory failure, acute valvular pathologies, tailoring and titrating intravenous treatment or mechanical circulatory support. This could be completed with trans-esophageal echocardiography (TOE), advanced echocardiography and lung ultrasound to provide a thorough evaluation and monitoring of CICU patients. However, CCE could sometimes be challenging as the acquisition of good-quality images is limited by mechanical ventilation, suboptimal patient position or recent surgery with drains on the chest. Moreover, there are some technical caveats that one should bear in mind while performing CCE in order to optimize its use and avoid misleading findings. The aim of this review is to highlight the key role of CCE, providing an updated overview of its main applications and possible pitfalls in order to facilitate its use in CICU for clinical decision-making.

COVID-19 pandemic and its impact on service provision: A cardiology prospect

Coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the availability of cardiology services and management of cardiac conditions. Elective surgeries, outpatient appointments and cardiac imaging have been largely cancelled across the world due to the risk of infection transmission and the need for reallocation of resources to deal with the increasing number of COVID-19 patients. The impact on patients with cardiac co-morbidities during these times may be drastic. However, cardiologists and hospitals across the world have implemented measures to ensure on-going monitoring and care of patients remotely. In this review, we discuss the impact of COVID-19 on cardiac services including interventional cardiology services, cardiac imaging and outpatient appointments. In addition, implications for future research and clinical practice are also discussed.

Pre-clinical medical student cardiac point-of-care ultrasound curriculum based on the American Society of Echocardiography recommendations: a pilot and feasibility study

Background

Cardiac point-of-care ultrasound (POCUS) training has been integrated into medical school curricula. However, there is no standardized cardiac POCUS training method for medical students. To address this issue, the American Society of Echocardiography (ASE) proposed a framework for medical student cardiac POCUS training. The objective of this pilot study was to develop a medical student cardiac POCUS curriculum with test scoring systems and test the curriculum feasibility for a future definitive study.

Methods

Based on the ASE-recommended framework, we developed a cardiac POCUS curriculum consisting of a pre-training online module and hands-on training with a hand-held ultrasound (Butterfly iQ, Butterfly Network Inc., Guilford, CT, USA). The curriculum learning effects were assessed with a 10-point maximum skill test and a 40-point maximum knowledge test at pre-, immediate post-, and 8-week post-training. To determine the curriculum feasibility, we planned to recruit 6 pre-clinical medical students. We semi-quantitatively evaluated the curriculum feasibility in terms of recruitment rate, follow-up rate 8 weeks after training, instructional design of the curriculum, the effect size (ES) of the test score improvements, and participant satisfaction. To gather validity evidence of the skill test, interrater and test-retest reliability of 3 blinded raters were assessed.

Results

Six pre-clinical medical students participated in the curriculum. The recruitment rate was 100% (6/6 students) and the follow-up rate 8 weeks after training was 100% (6/6). ESs of skill and knowledge test score differences between pre- and immediate post-, and between pre- and 8-week post-training were large. The students reported high satisfaction with the curriculum. Both interrater and test-retest reliability of the skill test were excellent.

Conclusions

This pilot study confirmed the curriculum design as feasible with instructional design modifications including the hands-on training group size, content of the cardiac POCUS lecture, hands-on teaching instructions, and hand-held ultrasound usage. Based on the pilot study findings, we plan to conduct the definitive study with the primary outcome of long-term skill retention 8 weeks after initial training. The definitive study has been registered in ClinicalTrials.gov (Identifier: NCT04083924).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00910-3.

How-to: Focus Cardiac Ultrasound in acute settings

Focus cardiac ultrasound (FoCUS) provides vital information at at the bedside which has the potential of improving outcomes in the acute settings. FoCUS could help the clinicians in their daily clinical decision-making while applied within the clinical context as an extension of bedside clinical examination. FoCUS practitioners should be aware of their own limitations with the importance of the timely referral for comprehensive Echocardiography whenever required.

Level 1 of Entrustable Professional Activities in adult echocardiography: a position statement from the EACVI regarding the training and competence requirements for selecting and interpreting echocardiographic examinations

The goal of Level 1 training in echocardiography is to enable the trainee to select echocardiography appropriately for the evaluation of a specific clinical question, and then to interpret the report. It is not the goal of Level 1 training to teach how to perform the examination itself-that is the goal of higher levels of training. However, understanding the principles, indications, and findings of this crucial technique is valuable to many medical professionals including outside cardiology. This should be seen as part of a general understanding of cardiac imaging modalities. The purpose of this position statement is to define the scope and outline the general requirements for Level 1 training and competence in echocardiography. Moreover, the document aims to make a clear distinction between Level 1 competence in echocardiography and focus cardiac ultrasound (FoCUS).

EACVI survey on multimodality training in ESC countries

One of the missions of the European Association of Cardiovascular Imaging (EACVI) is 'to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging'. The future of imaging involves multimodality so each imager should have the incentive and the possibility to improve its knowledge in other cardiovascular techniques. This article presents the results of a 20 questions survey carried out in cardiovascular imaging (CVI) centres across Europe. The aim of the survey was to assess the situation of experience and training of CVI in Europe, the availability and organization of modalities in each centre and to ask for vision about potential improvements in CVI at national and European level.

Case Report: Multimodality Imaging as a Lifeline for Fatal Localization of Valsalva Sinus Fibroelastoma

Background: Papillary fibroelastomas are rare benign heart tumors, and is most likely to involve the cardiac valves. We will present an extremely rare localization of a large Valsalva sinus fibroelastoma, with occasional left coronary artery ostial obstruction presented as an acute coronary syndrome. The tumor was removed surgically and histologically confirmed as papillary fibroelastoma. This review points to the crucial importance of multidisciplinary team decision and multimodality imaging methods for diagnosing the fibroelastoma, determination of size, and localization, which avoided complications of fatal embolization during an invasive procedure.

Case Summary: A healthy 55-year-old male with vigorous physical daily training and exercise was admitted to the acute coronary syndrome emergency department. Shortly after admission, expert transthoracic echocardiography was performed. Computed tomography of the chest observed a large irregular hypodense tumor-like lesion in the bulbar aorta that was occasionally prolapsing into the left main coronary artery ostium and which corresponded to fibroelastoma. A few hours after admission, an emergency cardiac surgery was performed with the excision of a Valsalva sinus tumor (size 2 × 2 cm) located between the right and left coronary cusp of the aortic valve.

Conclusions: Focus cardiac ultrasound should be performed for any acute coronary syndrome because of the possible Valsalva sinus fibroelastoma etiology. Its localization next to the left main coronary artery ostium is rare, and dangerous. The timely diagnosis can be made by the multimodality imaging method, however, the final diagnosis will be made pathohistologically. Early cardiac surgery may be a necessitated recourse for these patients in order to prevent a fatal outcome.

Prognostic value of right ventricular dilatation in patients with COVID-19: a multicentre study

Aims

Although cardiac involvement has prognostic significance in coronavirus disease 2019 (COVID-19) and is associated with severe forms, few studies have explored the prognostic role of transthoracic echocardiography (TTE). We investigated the link between TTE parameters and prognosis in COVID-19.

Methods and results

Consecutive patients with COVID-19 admitted to 24 French hospitals were retrospectively included. Comprehensive data, including clinical and biological parameters, were recorded at admission. Focused TTE was performed during hospitalization, according to clinical indication. Patients were followed for a primary composite outcome of death or transfer to intensive care unit (ICU) during hospitalization. Among 2878 patients, 445 (15%) underwent TTE. Most of these had cardiovascular risk factors, a history of cardiovascular disease, and were on cardiovascular treatments. Dilatation and dysfunction were observed in, respectively, 12% (48/412) and 23% (102/442) of patients for the left ventricle, and in 12% (47/407) and 16% (65/402) for the right ventricle (RV). Primary composite outcome occurred in 44% (n = 196) of patients [9% (n = 42) for death without ICU transfer and 35% (n = 154) for admission to ICU]. RV dilatation was the only TTE parameter associated with the primary outcome. After adjustment, male sex [hazard ratio (HR) 1.56, 95% confidence interval (CI) 1.09 − 2.25; P = 0.02], higher body mass index (HR 1.10, 95% CI 1.02 − 1.18; P = 0.01), anticoagulation (HR 0.53, 95% CI 0.33 − 0.86; P = 0.01), and RV dilatation (HR 1.66, 95% CI 1.05 − 2.64; P = 0.03) remained independently associated with the primary outcome.

Conclusion

Echocardiographic evaluation of RV dilatation could be useful for assessing risk of severe COVID-19 developing in hospitalized patients.

Artificial Intelligence-Powered Measurement of Left Ventricular Ejection Fraction Using a Handheld Ultrasound Device

The aim of this study was to assess the accuracy of an algorithm for automated measurement of left ventricular ejection fraction (LVEF) available on handheld ultrasound devices (HUDs). One hundred twelve patients admitted to the cardiology department underwent assessment performed with an HUD. In each case, the four-chamber apical view was obtained, and LVEF was calculated with LVivo software. Subsequently, during the examination performed with the use of the stationary echocardiograph, the 3-D measurement of LVEF was recorded. The average LVEFs measured with LVivo and the 3-D reference method were 46 ± 14% and 48 ± 14%, respectively. The correlation between the measurements obtained with the HUD and 3-D evaluation was high (r = 0.92, 95% confidence interval: 0.87-0.95, p < 0.0001). The mean difference between the LVEF obtained with LVivo and the 3-D LVEF was not significant (mean difference: -0.61%, 95% confidence interval: -1.89 to 0.68, p = 0.31). The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality.

Noninvasive Assessment of Ventricular-Arterial Coupling in Heart Failure

The heart and the arterial system are anatomically and functionally linked together. Noninvasive assessment of ventricular-arterial coupling (VAC) can be done using different methods that are promising tools to assess individual hemodynamics and tailor treatment in patients with heart failure (HF). Moreover, different methods available can be appropriately used in different settings such as acute and chronic HF. VAC parameters also can add incremental value over the conventional risk factors in predicting cardiac outcome.

Good clinical practice for the use of vasopressor and inotropic drugs in critically ill patients: state-of-the-art and expert consensus

Vasopressors and inotropic agents are widely used in critical care. However, strong evidence supporting their use in critically ill patients is lacking in many clinical scenarios. Thus, the Italian Society of Anesthesia and Intensive Care (SIAARTI) promoted a project aimed to provide indications for good clinical practice on the use of vasopressors and inotropes, and on the management of critically ill patients with shock. A panel of 16 experts in the field of intensive care medicine and hemodynamics has been established. Systematic review of the available literature was performed based on PICO questions. Basing on available evidence, the panel prepared a summary of evidence and then wrote the clinical questions. A modified semi-quantitative RAND/UCLA appropriateness method has been used to determine the appropriateness of specific clinical scenarios. The panel identified 29 clinical questions for the use of vasopressors and inotropes in patients with septic shock and cardiogenic shock. High level of agreement exists among the panel members about appropriateness of inotropes/vasopressors' use in patients with septic shock and cardiogenic shock.

Right Atrial Thrombosis and Pulmonary Embolism: A Narrative Review

Prompt diagnosis of pulmonary embolism (PE) remains challenging, which often results in a delayed or inappropriate treatment of this life-threatening condition. Mobile thrombus in the right cardiac chambers is a neglected cause of PE. It poses an immediate risk to life and is associated with an unfavorable outcome and high mortality. Thrombus residing in the right atrial appendage (RAA) is an underestimated cause of PE, especially in patients with atrial fibrillation. This article reviews achievements and challenges of detection and management of the right atrial thrombus with emphasis on RAA thrombus. The capabilities of transthoracic and transesophageal echocardiography and advantages of three-dimensional and two-dimensional echocardiography are reviewed. Strengths of cardiac magnetic resonance imaging (CMR), computed tomography, and cardiac ventriculography are summarized. We suggest that a targeted search for RAA thrombus is necessary in high-risk patients with PE and atrial fibrillation using transesophageal echocardiography and/or CMR when available independently on the duration of the disease. High-risk patients may also benefit from transthoracic echocardiography with right parasternal approach. The examination of high-risk patients should involve compression ultrasonography of lower extremity veins along with the above-mentioned technologies. Algorithms for RAA thrombus risk assessment and protocols aimed at identification of patients with RAA thrombosis, who will potentially benefit from treatment, are warranted. The development of treatment protocols specific for the diverse populations of patients with right cardiac thrombosis is important.