Variation in the Echocardiographic Surveillance of Primary Mitral Regurgitation

Use of an ultrasound picture archiving and communication system to answer research questions: Description of data cleaning methods

Introduction/Purpose

Ultrasound picture archiving and communication system (PACS) databases are useful for quality improvement and clinical research but frequently contain free text that is not easily readable. Here, we present a method to extract and clean a semi-structured echocardiography (cardiac ultrasound) PACS database.

Methods

Echocardiography studies between 1 January 2010 and 31 December 2018 were extracted using a data mining tool. Numeric variables were recoded with extreme values excluded. Analysis of free text, including descriptions of the heart valves and right and left ventricular size and function, was performed using a rule-based system. Different levels of free text variables were initially identified using commonly used phrases and then iteratively developed. Randomly selected sets of 100 studies were compared to the electronic health record to validate the data cleaning process.

Results

The data validation step was performed three times in total, with Cohen's kappa ranging between 0.88 and 1.00 for the final set of data validation across all measures.

Conclusion

Free text cleaning of semi-structured PACS databases is possible using freely available open-source software. The accuracy of this method is high, and the resulting dataset can be linked to administrative data to answer research questions. We present a method that could be used to answer clinical questions or to develop quality improvement initiatives.

Development and validation of an echocardiographic algorithm to predict long-term mitral and tricuspid regurgitation progression

AIMS

Prediction of mitral (MR) and tricuspid (TR) regurgitation progression on transthoracic echocardiography (TTE) is needed to personalize valvular surveillance intervals and prognostication.

METHODS AND RESULTS

Structured TTE report data at Beth Israel Deaconess Medical Center, 26 January 2000-31 December 2017, were used to determine time to progression (≥1+ increase in severity). TTE predictors of progression were used to create a progression score, externally validated at Massachusetts General Hospital, 1 January 2002-31 December 2019. In the derivation sample (MR, N = 34 933; TR, N = 27 526), only 5379 (15.4%) individuals with MR and 3630 (13.2%) with TR had progression during a median interquartile range) 9.0 (4.1-13.4) years of follow-up. Despite wide inter-individual variability in progression rates, a score based solely on demographics and TTE variables identified individuals with a five- to six-fold higher rate of MR/TR progression over 10 years (high- vs. low-score tertile, rate of progression; MR 20.1% vs. 3.3%; TR 21.2% vs. 4.4%). Compared to those in the lowest score tertile, those in the highest tertile of progression had a four-fold increased risk of mortality. On external validation, the score demonstrated similar performance to other algorithms commonly in use.

CONCLUSION

Four-fifths of individuals had no progression of MR or TR over two decades. Despite wide interindividual variability in progression rates, a score, based solely on TTE parameters, identified individuals with a five- to six-fold higher rate of MR/TR progression. Compared to the lowest tertile, individuals in the highest score tertile had a four-fold increased risk of mortality. Prediction of long-term MR/TR progression is not only feasible but prognostically important.

Mortality Due to Mitral Regurgitation Among Adults in the United States: 1999-2018

OBJECTIVE

To evaluate the nationwide trends in mortality due to mitral regurgitation (MR) among American adults from 1999 to 2018.

PATIENTS AND METHODS

Trends in mortality due to MR were assessed using retrospective cross-sectional analyses of nationwide mortality data from death certificates of all American residents between January 1, 1999, and December 31, 2018, using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Piecewise linear regression was used to evaluate the trends in the overall population and in subgroups.

RESULTS

Among 45,982 deaths due to MR during the study period, higher mortality rates were seen in older White females from the western United States. In 1999, the crude and age-adjusted mortality rates were 27.4 (95% CI, 26.3 to 28.4) and 27.5 (95% CI, 26.4 to 28.5) per 1,000,000 persons, respectively. By 2018, these rates declined to 18.0 (95% CI, 17.3 to 18.7) and 17.7 (95% CI, 17.0 to 18.4) per 1,000,000 persons, respectively (P<.001 for trend for both). Crude mortality rates declined from 1999 to 2012 (annual percentage change [APC], -4.1 (95% CI, -4.6 to -3.6) but then increased after 2012 (APC, 2.6 [95% CI, 0.8 to 4.4; P<.001 for change in trend]). The age-adjusted mortality rates declined from 1999 to 2012 (APC, -3.9 [95% CI, -4.4 to -3.4]) but subsequently increased after 2012 (APC, 1.4 [95% CI, -0.4 to 3.2; P<.001 for change in trend]). The observed decrease was consistent across age, sex, race, geographic region, and urbanization subgroups (P<.05 for all).

CONCLUSION

Mortality due to MR in American adults declined at an annual rate of approximately 4% until 2012 and has since then increased by about 1.5% annually. These mortality trends warrant further investigation.

Identification of Need for Ultrasound Enhancing Agent Study (the IN-USE Study)

BACKGROUND

Ultrasound enhancing agents (UEAs) are routinely used to improve transthoracic echocardiographic (TTE) image quality, yet anticipation of UEA need is a barrier to their use.

METHODS

Structured report data from 171,509 consecutive TTE studies in 97,515 patients who underwent TTE imaging from January 26, 2000, to September 20, 2018, were analyzed. Trends in UEA use and suboptimal image quality were examined. Among outpatients (92,291 TTE examinations, n = 56,479), the data set was randomly split into a 75% derivation sample and a 25% validation sample. Logistic regression was used to model the composite of either UEA receipt or suboptimal image quality (two or more nonvisualized segments) using only variables available at the start of the TTE examination. Model performance was tested in the validation sample.

RESULTS

A total of 4,444 TTE examinations (2.6%) in 3,827 patients (3.9%) involved UEAs, and 28,468 TTE examinations (16.6%) in 21,994 patients (22.5%) were suboptimal. UEA use increased over the observation period. Among TTE studies with suboptimal image quality, UEA use was lower in women (P < .0001). Among outpatients referred for TTE imaging, older age, greater weight, and higher heart rate best predicted UEA use or suboptimal image quality. Model performance in the validation sample was excellent (C statistic = 0.74 [95% CI, 0.73-0.75]; calibration slope = 1.11 [95% CI, 1.06-1.15]).

CONCLUSIONS

In this large, single-center, retrospective study, UEA use remained substantially below rates of suboptimal image quality, despite increases over time. Among outpatients, a simple prediction rule using three routinely collected variables available before TTE image acquisition predicted potential benefit from UEAs with high accuracy. If confirmed in other cohorts, this rule may be used to identify patients who may benefit from intravenous placement for UEA administration before TTE image acquisition, thus potentially improving work-flow efficiency.

Priorities for Patient-Centered Research in Valvular Heart Disease: A Report From the National Heart, Lung, and Blood Institute Working Group

Over the past decade, the field of valvular heart disease (VHD) has rapidly transformed, largely as a result of the development and improvement of less invasive transcatheter approaches to valve repair or replacement. This transformation has been supported by numerous well-designed randomized trials, but they have centered almost entirely on devices and procedures. Outside this scope of focus, however, myriad aspects of therapy and management for patients with VHD have either no guidelines or recommendations based only on expert opinion and observational studies. Further, research in VHD has often failed to engage patients to inform study design and identify research questions of greatest importance and relevance from a patient perspective. Accordingly, the National Heart, Lung, and Blood Institute convened a Working Group on Patient-Centered Research in Valvular Heart Disease, composed of clinician and research experts and patient advocacy experts to identify gaps and barriers to research in VHD and identify research priorities. While recognizing that important research remains to be done to test the safety and efficacy of devices and procedures to treat VHD, we intentionally focused less attention on these areas of research as they are more commonly pursued and supported by industry. Herein, we present the patient-centered research gaps, barriers, and priorities in VHD and organized our report according to the "patient journey," including access to care, screening and diagnosis, preprocedure therapy and management, decision making when a procedure is contemplated (clinician and patient perspectives), and postprocedure therapy and management. It is hoped that this report will foster collaboration among diverse stakeholders and highlight for funding bodies the pressing patient-centered research gaps, opportunities, and priorities in VHD in order to produce impactful patient-centered research that will inform and improve patient-centered policy and care.

Association Between Transthoracic Echocardiography Appropriateness and Echocardiographic Findings

BACKGROUND

The association between appropriate use criteria and echocardiographic findings in patients with chronic cardiovascular diseases is unknown.

METHODS

As a substudy of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial, 9,230 transthoracic echocardiographic (TTE) examinations from six Ontario academic hospitals were linked to a registry of echocardiographic findings. The TTE studies were rated appropriate), rarely appropriate, or may be appropriate according to the 2011 appropriate use criteria. TTE findings of appropriately ordered examinations were compared with those of rarely appropriate examinations for specific disease subsets, including heart failure and valvular heart disease.

RESULTS

There were 7,574, 1,087, and 569 TTE examinations ordered for appropriate, rarely appropriate, and may be appropriate indications, and of the 7,574 appropriate studies, 6,399 were ordered for specific indications and 1,175 for general indications. TTE examinations ordered for general indications had lower rates of left ventricular dysfunction (19.6% vs 9.1%, P < .001) and moderate to severe aortic stenosis (15.5% vs 2.6%, P < .001). Of the 2,395 TTE examinations ordered for patients with heart failure, appropriately ordered studies were more likely to result in left ventricular segmental abnormality (37.0% vs 24.9%, P = .012) but similar rates of right ventricular dilatation (15.4% vs 14.7%, P = .79), right ventricular dysfunction (14.8% vs 11.3%, P = .22), and moderate to severe mitral regurgitation (12.1% vs 9.2%, P = .35). Of the 2,859 studies ordered to assess valvular heart disease, appropriately ordered studies were significantly more likely to find moderate to severe valvular pathology, including aortic stenosis (30.4% vs 24.6%, P = .008), aortic regurgitation (8.9% vs 1.6%, P < .001), mitral stenosis (6.7% vs 3.1%, P = .002), and mitral regurgitation (16.1% vs 6.1%, P < .001), but similar rates of tricuspid regurgitation (11.2% vs 13.0%, P = .60).

CONCLUSIONS

Overall, appropriately ordered TTE examinations for heart failure and valvular heart disease were significantly more likely to have abnormal findings than rarely appropriate examinations. TTE studies ordered for general indications had fewer, although still a significant proportion, of abnormalities compared with studies ordered for specific indications.