Left Ventricular Geometric Abnormality Screening in Hypertensive Patients Using a Hand-Carried Ultrasound Device

Clinical comparison of a handheld cardiac ultrasound device for the assessment of left ventricular function

PURPOSE

Recently developed handheld ultrasound devices (HHUD) represent a promising method to evaluate the cardiovascular abnormalities at the point of care. However, this technology has not been rigorously evaluated. The aim of this study was to explore the correlation and the agreement between the LVEF (Left Ventricular Ejection Fraction) visually assessed by a moderately experienced sonographer using an HHUD compared to the routine LVEF assessment performed at the Echocardiography Laboratory.

METHODS

This was a prospective single center study which enrolled 120 adult inpatients and outpatients referred for a comprehensive Echocardiography (EC).

RESULTS

The mean age of the patients was 69.9 ± 12.5 years. There were 47 females (39.2%). The R-squared was r 0.94 (p < 0.0001) and the ICC was 0.93 (IC 95% 0.91-0.95, p ≤ 0.0001). The Bland-Altman plot showed limits of agreement (LOA): Upper LOA 10.61 and Lower LOA - 8.95. The overall agreement on the LVEF assessment when it was stratified as "normal" or "reduced" was 89.1%, with a kappa of 0.77 (p < 0.0001). When the LVEF was classified as "normal", "mildly reduced", "moderately reduced", or "severely reduced," the kappa was 0.77 (p < 0.0001). The kappa between the HHUD EC and the comprehensive EC for the detection of RWMAs in the territories supplied by the LAD, LCX and RCA was 0.85, 0.73 and 0.85, respectively.

CONCLUSION

With current HHUD, an averagely experienced operator can accurately bedside visual estimate the LVEF. This may facilitate the incorporation of this technology in daily clinical practice improving the management of patients.

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.

Diagnostic accuracy of handheld cardiac ultrasound device for assessment of left ventricular structure and function: systematic review and meta-analysis

Objective

Handheld ultrasound devices (HUD) has diagnostic value in the assessment of patients with suspected left ventricular (LV) dysfunction. This meta-analysis evaluates the diagnostic ability of HUD compared with transthoracic echocardiography (TTE) and assesses the importance of operator experience.

Methods

MEDLINE and EMBASE databases were searched in October 2020. Diagnostic studies using HUD and TTE imaging to determine LV dysfunction were included. Pooled sensitivities and specificities, and summary receiver operating characteristic curves were used to determine the diagnostic ability of HUD and evaluate the impact of operator experience on test accuracy.

Results

Thirty-three studies with 6062 participants were included in the meta-analysis. Experienced operators could predict reduced LV ejection fraction (LVEF), wall motion abnormality (WMA), LV dilatation and LV hypertrophy with pooled sensitivities of 88%, 85%, 89% and 85%, respectively, and pooled specificities of 96%, 95%, 98% and 91%, respectively. Non-experienced operators are able to detect cardiac abnormalities with reasonable sensitivity and specificity. There was a significant difference in the diagnostic accuracy between experienced and inexperienced users in LV dilatation, LVEF (moderate/severe) and WMA. The diagnostic OR for LVEF (moderate/severe), LV dilatation and WMA in an experienced hand was 276 (95% CI 58 to 1320), 225 (95% CI 87 to 578) and 90 (95% CI 31 to 265), respectively, compared with 41 (95% CI 18 to 94), 45 (95% CI 16 to 123) and 28 (95% CI 20 to 41), respectively, for inexperienced users.

Conclusion

This meta-analysis is the first to establish HUD as a powerful modality for predicting LV size and function. Experienced operators are able to accurately diagnose cardiac disease using HUD. A cautious, supervised approach should be implemented when imaging is performed by inexperienced users. This study provides a strong rationale for considering HUD as an auxiliary tool to physical examination in secondary care, to aid clinical decision making when considering referral for TTE.

Trial registration number

CRD42020182429.

Ultrasound Hypotension Protocol Time-motion Study Using the Multifrequency Single Transducer Versus a Multiple Transducer Ultrasound Device

INTRODUCTION

Ultrasound hypotension protocols (UHP) involve imaging multiple body areas, each with different transducers and imaging presets. The time for task switching between presets and transducers to perform an UHP has not been previously studied. A novel hand-carried ultrasound (HCU) has been developed that uses a multifrequency single transducer to image areas of the body (lung, heart, abdomen, superficial) that would typically require three transducers using a traditional cart-based ultrasound (CBU) system. Our primary aim was to compare the time to complete UHPs with a single transducer HCU to a multiple transducer CBU.

METHODS

We performed a randomized, crossover feasibility trial in the emergency department of an urban, safety-net hospital. This was a convenience sample of non-hypotensive emergency department patients presenting during a two-month period of time. Ultrasound hypotension protocols were performed by emergency physicians (EP) on patients using the HCU and the CBU. The EPs collected UHP views in sequential order using the most appropriate transducer and preset for the area/organ to be imaged. Time to complete each view, time for task switching, total time to complete the examination, and image diagnostic quality were recorded.

RESULTS

A total of 29 patients were scanned by one of eight EPs. When comparing the HCU to the CBU, the median time to complete the UHP was 4.3 vs 8.5 minutes (P <0.0001), respectively. When the transport and plugin times were excluded, the median times were 4.1 vs 5.8 minutes (P <0.0001), respectively. There was no difference in the diagnostic quality of images obtained by the two devices.

CONCLUSION

Ultrasound hypotension protocols were performed significantly faster using the single transducer HCU compared to a multiple transducer CBU with no difference in the number of images deemed to be diagnostic quality.

Defining the Role of Point-of-Care Ultrasound in Cardiovascular Disease

Echocardiography is the foundation for diagnostic cardiac testing, allowing for direct identification and management of various conditions. Point-of-care ultrasound (POCUS) has emerged as an invaluable tool for bedside diagnosis and management. The objective of this review is to address the current use and clinical applicability of POCUS to identify, triage, and manage a wide spectrum of cardiac conditions. POCUS can change diagnosis and management decisions of various cardiovascular conditions in a range of settings. In the outpatient setting, it is used to risk stratify and diagnose a variety of medical conditions. In the emergency department (ED) and critical care settings, it is used to guide triage and critical care interventions. Furthermore, the skills needed to perform POCUS can be taught to noncardiologists in a way that is retained and allows identification of normal and grossly abnormal cardiac findings. Various curricula have been developed that teach residents and advanced learners how to appropriately employ point-of-care ultrasound. In conclusion, POCUS can be a useful adjunct to the physical exam, particularly in critical care applications.

Consensus Document of the SEMI, semFYC, SEN, and SEC on Focused Cardiac Ultrasound in Spain

This document summarizes the concept of focused cardiac ultrasound, the basic technical aspects related to this technique, and its diagnostic objectives. It also defines training requisites in focused cardiac ultrasound. This consensus document has been endorsed by the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of Neurology (SEN), and the Spanish Society of Cardiology (SEC).

Hospital Medicine Point of Care Ultrasound Credentialing: An Example Protocol

Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.

Focused cardiac ultrasound: where do we stand?

Focused cardiac ultrasound (FCU) is a bedside examination of the heart performed with a small, portable ultrasound platform by a physician as an adjunct to their physical examination. The goal is to recognize a narrow list of abnormalities that are both detectable by physicians with limited ultrasound training and have high clinical assessment value. Results from the FCU examination are integrated with traditional bedside assessment (physical examination and history) to provide early management plans and patient triage in settings when echocardiography cannot be obtained or is not immediately available.