Association Between Echocardiography Laboratory Accreditation and the Quality of Imaging and Reporting for Valvular Heart Disease

Cardiac magnetic resonance imaging in the evaluation and management of mitral valve prolapse - a comprehensive review

Mitral valve prolapse is a common valve disorder that usually has a benign prognosis unless there is significant regurgitation or LV impairment. However, a subset of patients are at an increased risk of ventricular arrhythmias and sudden cardiac death, which has led to the recognition of "arrhythmic mitral valve prolapse" as a clinical entity. Emerging risk factors include mitral annular disjunction and myocardial fibrosis. While echocardiography remains the primary method of evaluation, cardiac magnetic resonance has become crucial in managing this condition. Cine magnetic resonance sequences provide accurate characterization of prolapse and annular disjunction, assessment of ventricular volumes and function, identification of early dysfunction and remodeling, and quantitative assessment of mitral regurgitation when integrated with flow imaging. However, the unique strength of magnetic resonance lies in its ability to identify tissue changes. T1 mapping sequences identify diffuse fibrosis, in turn related to early ventricular dysfunction and remodeling. Late gadolinium enhancement sequences detect replacement fibrosis, an independent risk factor for ventricular arrhythmias and sudden cardiac death. There are consensus documents and reviews on the use of cardiac magnetic resonance specifically in arrhythmic mitral valve prolapse. However, in this article, we propose an algorithm for the broader use of cardiac magnetic resonance in managing this condition in various scenarios. Future advancements may involve implementing techniques for tissue characterization and flow analysis, such as 4D flow imaging, to identify patients with ventricular dysfunction and remodeling, increased arrhythmic risk, and more accurate grading of mitral regurgitation, ultimately benefiting patient selection for surgical therapy.

Practical Considerations for Obtaining Perioperative Transesophageal Echocardiography Accreditation: Collective Experiences at Early-Adopting Centers

The Intersocietal Accreditation Commission (IAC) is a nonprofit accrediting organization committed to ensuring the quality of diagnostic imaging and related procedures. It comprises a collaboration of stakeholders spanning numerous medical professionals and specialties. In a recent initiative, IAC Echocardiography introduced a new accreditation specifically for Perioperative Transesophageal Echocardiography (PTE). This accreditation process is anchored in rigorous clinical peer review to ensure diagnostic quality and report accuracy, thus maintaining high standards of medical care. The authors present the inaugural 4 sites to achieve IAC accreditation for PTE, which have collaborated to share their experiences in achieving this accreditation. This review endeavors to offer actionable insights and proven solutions to navigate the accreditation journey for others. Mirroring the IAC Standards and Guidelines for PTE accreditation, this review is divided into three pivotal sections as follows: (1) organization of a perioperative echocardiography service, including stakeholder engagement to facilitate the application for accreditation; (2) performance of examinations and reporting; and (3) instituting quality improvement strategies and establishing a robust program. The pursuit of accreditation in PTE is to transcend a mere compliance exercise. It signifies a dedication to excellence, continual growth, and, above all, to the well-being of patients.

Diagnosis of Coexisting Valvular Heart Diseases Using Image-to-Sequence Translation of Contact Microphone Recordings

OBJECTIVE

Development of a contact microphone-driven screening framework for the diagnosis of coexisting valvular heart diseases (VHDs).

METHODS

A sensitive accelerometer contact microphone (ACM) is employed to capture heart-induced acoustic components on the chest wall. Inspired by the human auditory system, ACM recordings are initially transformed into Mel-frequency cepstral coefficients (MFCCs) and their first and second derivatives, resulting in 3-channel images. An image-to-sequence translation network based on the convolution-meets-transformer (CMT) architecture is then applied to each image to find local and global dependencies in images, and predict a 5-digit binary sequence, where each digit corresponds to the presence of a specific type of VHD. The performance of the proposed framework is evaluated on 58 VHD patients and 52 healthy individuals using a 10-fold leave-subject-out cross-validation (10-LSOCV) approach.

RESULTS

Statistical analyses suggest an average sensitivity, specificity, accuracy, positive predictive value, and F1 score of 93.28%, 98.07%, 96.87%, 92.97%, and 92.4% respectively, for the detection of coexisting VHDs. Furthermore, areas under the curve (AUC) of 0.99 and 0.98 are respectively reported for the validation and test sets.

CONCLUSION

The high performances achieved prove that local and global features of ACM recordings effectively characterize heart murmurs associated with valvular abnormalities.

SIGNIFICANCE

Limited access of primary care physicians to echocardiography machines has resulted in a low sensitivity of 44% when using a stethoscope for the identification of heart murmurs. The proposed framework provides accurate decision-making on the presence of VHDs, thus reducing the number of undetected VHD patients in primary care settings.

Diagnostic role of aortic valve calcium scoring in various etiologies of aortic stenosis

Most of the studies about aortic valve calcium (AVC) score in aortic stenosis (AS) were based on degenerative or bicuspid AS but not rheumatic AS. We aimed to study the diagnostic accuracy of AVC score to determine severe AS in various etiologies. Adult patients diagnosed with mild to severe AS were enrolled. AVC score were identified from multi-detector computed tomography (MDCT) scan. The AVC score was highest in bicuspid AS (3211.9 (IQR (1100.0-4562.4) AU) compared to degenerative AS (1803.7 (IQR (1073.6-2550.6) AU)), and rheumatic AS (875.6 (IQR 453.3-1594.0) AU), p < 0.001. For the ROC curve to identify severe AS, the AVC score performed well in degenerative and bicuspid AS with the area under the ROC curve (AuROC) 0.834 (95% CI, 0.730, 0.938) in degenerative group; and 0.820 (95% CI, 0.687, 0.953) in bicuspid AS. Whereas AVC score had non-significant diagnostic accuracy with AuROC 0.667 (95% CI, 0.357, 0.976) for male and 0.60(95% CI, 0.243, 0.957) for female in rheumatic AS. The cut-off AVC score values to identify severe AS were AVCS > 2028.9AU (male) and > 1082.5AU (female) for degenerative AS, and > 2431.8AU (male) and > 1293.5AU (female) for bicuspid AS. In conclusions, AVC score is the accurate test for assessing severity in patients with degenerative and bicuspid AS but performs poorly in rheumatic AS group.

Machine learning derived echocardiographic image quality in patients with left ventricular systolic dysfunction: insights on the echo views of greatest image quality

We sought to determine the cardiac ultrasound view of greatest quality using a machine learning (ML) approach on a cohort of transthoracic echocardiograms (TTE) with abnormal left ventricular (LV) systolic function. We utilize an ML model to determine the TTE view of highest quality when scanned by sonographers. A random sample of TTEs with reported LV dysfunction from 09/25/2017-01/15/2019 were downloaded from the regional database. Component video files were analyzed using ML models that jointly classified view and image quality. The model consisted of convolutional layers for extracting spatial features and Long Short-term Memory units to temporally aggregate the frame-wise spatial embeddings. We report the view-specific quality scores for each TTE. Pair-wise comparisons amongst views were performed with Wilcoxon signed-rank test. Of 1,145 TTEs analyzed by the ML model, 74.5% were from males and mean LV ejection fraction was 43.1 ± 9.9%. Maximum quality score was best for the apical 4 chamber (AP4) view (70.6 ± 13.9%, p<0.001 compared to all other views) and worst for the apical 2 chamber (AP2) view (60.4 ± 15.4%, p<0.001 for all views except parasternal short-axis view at mitral/papillary muscle level, PSAX M/PM). In TTEs scanned by professional sonographers, the view with greatest ML-derived quality was the AP4 view.

MitraClip to the Rescue in Cardiogenic Shock: Case Series from a Single Center

Cardiogenic shock (CS) in the setting of acute coronary syndrome carries detrimental consequences and high levels of mortality and morbidity if not managed promptly. Acute mitral regurgitation (MR) as a complication of the myocardial infarction might superimpose refractory CS that warrants mitral valve repair. There has been growing use of Transcatheter edge-to-edge mitral valve repair (TEER) as a therapy for CS secondary to acute MR. In this cohort, we describe two cases of CS secondary to acute ischemic MR managed with a Mitraclip.

Durable Robotic Mitral Repair of Degenerative Primary Regurgitation With Long-Term Follow-Up

BACKGROUND

Variation in degenerative mitral morphology may contribute to suboptimal repair rates. This study evaluates outcomes of a standardized mitral repair technique.

METHODS

An institutional clinical registry was used to identify 1036 consecutive patients undergoing robotic mitral surgery between 2005 and 2020: 87% (n = 902) had degenerative disease. Calcification, failed transcatheter repair, and endocarditis were excluded, leaving 582 (68%) patients with isolated posterior leaflet and 268 (32%) with anterior or bileaflet prolapse. Standardized repair comprised triangular resection and true-sized flexible band in posterior leaflet prolapse. Freedom from greater than 2+ moderate mitral regurgitation stratified by prolapse location was assessed using competing risk analysis with death as a competing event. Median follow-up was 5.5 (range 0-15) years.

RESULTS

Of patients with isolated posterior leaflet prolapse, 87% (n = 506) had standardized repairs and 13% (n = 76) had additional or nonresectional techniques vs 24% (n = 65) and 76% (n = 203), respectively, for anterior or bileaflet prolapse (P < .001). Adjunctive techniques in the isolated posterior leaflet group included chordal reconstruction (8.6%, n = 50) and commissural sutures (3.4%, n = 20). Overall, median clamp time was 80 (interquartile range, 68-98) minutes, 17 patients required intraoperative re-repair, and 6 required mitral replacement. Freedom from greater than 2+ regurgitation or reintervention at 10 years was 92% for posterior prolapse (vs 83% for anterior or bileaflet prolapse). Anterior or bileaflet prolapse was associated with late greater than 2+ regurgitation (hazard ratio, 3.0; 95% confidence interval, 1.3-7.0).

CONCLUSIONS

Posterior leaflet prolapse may be repaired in greater than 99% of patients using triangular resection and band annuloplasty, with satisfactory long-term durability. Increased risk of complex repairs and inferior durability highlights the value of identifying anterior and bileaflet prolapse preoperatively.

Variation in additional testing and patient outcomes after stress echocardiography or myocardial perfusion imaging, according to accreditation status of testing site

BACKGROUND

The purpose of the present study was to determine whether patients receiving a stress echocardiogram or myocardial perfusion imaging (MPI) test have differences in subsequent testing and outcomes according to accreditation status of the original testing facility.

METHODS AND RESULTS

An all-payer claims dataset from Maine Health Data Organization from 2012 to 2014 was utilized to define two cohorts defined by an initial stress echocardiogram or MPI test. The accreditation status (Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) or none) of the facility performing the index test was known. Descriptive statistics and multivariate regression were used to examine differences in subsequent diagnostic testing and cardiac outcomes. We observed 4603 index stress echocardiograms and 8449 MPI tests. Multivariate models showed higher odds of subsequent MPI testing and hospitalization for angina if the index test was performed at a non-accredited facility in both the stress echocardiogram cohort and the MPI cohort. We also observed higher odds of percutaneous coronary interventions (PCI) performed (OR 1.68, 95% CI 1.13-2.50), if the initial MPI test was done in a non-accredited facility.

CONCLUSION

Cardiac testing completed in non-accredited facilities were associated with higher odds of subsequent MPI testing, hospitalization for angina, and PCI.

Development and validation of a novel image quality rating scale for echocardiography during cardiac arrest

Objective

Research into echocardiography (echo) during cardiac arrest has suffered from methodological flaws that limit aggregation of findings. We developed and validated a novel image rating scale for qualitative analysis of echo images obtained during resuscitation.

Methods

A novel 5-point ordinal rating scale was developed and validated using recorded echo images from 145 consecutive cardiac arrest patients. Recorded echo images were reviewed in a blinded fashion by investigators experienced in cardiac arrest echo, and image quality was rated using this scale. Cardiac activity was subsequently classified as no activity, disorganized activity and organized activity. The primary outcome was inter-rater agreement using the image quality rating scale. Secondary outcome was the qualitative evaluation of the type of cardiac activity.

Results

A total of 235 ultrasounds were analyzed by study investigators using the image quality rating scale. The overall image quality agreement between reviewers using the scale was good with a weighted kappa of 0.65. Agreement for image quality in subxyphoid images was greater than in parasternal images (0.65-0.52). Echo analysis of cardiac activity showed no activity (33%), disorganized activity (18%), and organized activity (49%). Agreement was great for presence or absence of "cardiac activity" and "organized cardiac activity" with a kappa of 0.84 and 0.78.

Conclusions

A novel image quality rating scale for echo during cardiac arrest demonstrates substantial agreement between reviewers. Agreement regarding the presence or absence, as well as the organization of cardiac activity was substantial.

The Echocardiography Society of Saudi Heart Association Recommendation on Quality and Laboratory Accreditation Guideline and Standards

Objective

To create the Saudi Arabian Society of Echocardiography Accreditation Commission Guidelines and Standards.

Method

A review of available the North American and European accreditation guidelines was conducted and a model, locally appropriate for Saudi echocardiography laboratories and applicable in the current settings, was developed.

Results

The document specifies the organizational setting as well as the following categories of personnel: medical director, technical director, medical staff, and technical staff. The guideline team also examined aspects related to the facility and the facility safety policies and protocols. Examination and procedural issues for Adult transthoracic echocardiography including instrumentation, archiving media, examination interpretation and reports are also included as well as the required components for the Adult transthoracic echocardiography report. The last section of the guidelines focuses on Key Performance Indicators. A similar approach was taken regarding the Adult Stress Echocardiography, Transesophageal Echo, and monitoring of the patients during the procedures.

Conclusion

The development of the Saudi Echocardiography Guidelines and Standards is a basic requirement for accreditation and also mandatory to improve the quality and utilization of such an important investigation.

Comprehensive Quality Improvement Program for Intraoperative Transesophageal Echocardiography: Development, Implementation, and Initial Experience

OBJECTIVE

To develop and implement a comprehensive transesophageal echocardiography (TEE) quality improvement (QI) program and assess for potential improvements in TEE performed by cardiac anesthesiologists.

DESIGN

Prospective institutionally approved QI program.

SETTING

Academic tertiary care center.

PARTICIPANTS

The study comprised cardiac anesthesiologists.

INTERVENTIONS

An instrument comprising 15 quality measures to assess TEE examinations pre- and post-cardiopulmonary bypass (CPB) was developed for the present study. TEE examinations before the introduction of the QI program were assessed retrospectively, and examinations performed after its introduction were reviewed prospectively over a 2-year period.

MEASUREMENTS AND MAIN RESULTS

A total of 118 TEE studies were analyzed, 48 and 70 studies before and after introduction of the TEE QI program, respectively. Half of the studies were performed pre-CPB, and half of them were performed post-CPB. Multivariate linear mixed regression models were used to assess the effect of the QI program. Interrater variability was assessed among internal reviewers by means of the Shrout-Fleiss reliability intraclass correlation coefficient. Five quality measures demonstrated a significant improvement in studies after CPB after implementation, including 3 imaging criteria (left ventricle, tricuspid valve, and pulmonary artery) and 2 documentation criteria (completeness of demographic/clinical data and timely reporting of documentation). The inter-rater variability analysis yielded an average intraclass correlation coefficient of 0.90 before and 0.78 after the QI program initiation, consistent with excellent agreement among the 4 reviewers.

CONCLUSIONS

The present study demonstrated the ability to create and implement a formal QI program for intraoperative TEE in an academic tertiary care cardiac surgical group. The initial data showed significant improvement in several quality measures related to TEE performance.

Stress echocardiography in coronary artery disease: a practical guideline from the British Society of Echocardiography

Stress echocardiography is an established technique for assessing coronary artery disease. It has primarily been used for the diagnosis and assessment of patients presenting with chest pain in whom there is an intermediate probability of coronary artery disease. In addition, it is used for risk stratification and to guide revascularisation in patients with known ischaemic heart disease. Although cardiac computed tomography has recently been recommended in the United Kingdom as the first-line investigation in patients presenting for the first time with atypical or typical angina, stress echocardiography continues to have an important role in the assessment of patients with lesions of uncertain functional significance and patients with known ischaemic heart disease who represent with chest pain. In this guideline from the British Society of Echocardiography, the indications and recommended protocols are outlined for the assessment of ischaemic heart disease by stress echocardiography.

The 21st Century Echocardiography Laboratory in Australia and New Zealand: Rapid Evolution of Training and Workforce, Practice and Technology

Echocardiography is a common and increasingly used noninvasive imaging tool in medicine. In this paper, we imagine the echocardiography laboratory of the future and consider the challenges we face currently, and may face in the future, and how these might be overcome; challenges such as training enough sonographers to meet the increasing demands of the ageing population living with chronic cardiovascular disease and the need for surveillance in other clinical scenarios. We consider the changing qualification framework and the requirements for accreditation and registration in Australia and New Zealand and the potential for migrant sonographers to meet some of the increasing demand. Advanced scopes of practice are likely to be a feature of the future workforce and we consider some of the ways these may evolve. Lastly, we consider how the evolving clinical landscape and technology may change the way echocardiography is delivered.

Accreditation, Credentialing, and Quality Improvement in Diagnostic Medical Sonography: A Literature Review

There are few regulations regarding facility accreditation and individual credentialing in diagnostic medical sonography (DMS), although it is known that the quality of examinations in the field can vary based by the operator. This literature review summarizes the findings from 19 research studies on accreditation, credentialing, and quality improvement and includes illustrative quotes from 23 position papers and 42 editorials. The review uncovered large differences in facility accreditation status based on sonography specialty and geographical area. The findings included many examples of positive correlations between accreditation and improved quality and also a positive correlation between credentialing and improved image quality. The survey studies revealed overwhelming support for accreditation and credentialing. Many articles raised concerns about the unknown quality of sonograms performed in nonaccredited facilities or by uncredentialed sonographers. If facility accreditation and/or individual credentialing could be implemented nationwide in DMS, it may lead to increased quality within the field.