Efficacy and learning curve of a hand-held echocardiography device in an oncology outpatient clinic: Expanding the use of echoscopic heart examination beyond cardiology

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Echoscopy in scanning cardiac diseases in critical care medicine

BACKGROUND AND AIMS

Targeted ultrasound examinations with a portable ultrasound device ("handheld ultrasound system"; HHUS) have been defined as "echoscopy" by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). Cardiac scanning with HHUS is feasible. Echoscopy could play a major role in emergency and intensive care medicine, but adequate data on its effectiveness are still lacking. Sonographic examinations in the field of emergency and intensive care medicine can often not be carried out under standardized examination conditions. Thus, the aim of this study is to show that the use of HHUS for echocardiography in emergency medicine is possible and that for this setting HHUS is not inferior to a high-end ultrasound system (HEUS) for detecting cardiac pathologies.

METHODS

The examinations were carried out with a Vscan™ (GE Medical Systems, Solingen, Germany) and a high-end ultrasound device (Acuson X‑300 or X‑700). The examinations were randomized and blinded to two examiners within 30 min. The examinations took place in the intensive care unit, the emergency room and the ambulance service. The results were recorded in an examination sheet.

RESULTS

In all, 93 patients (61 men and 32 women, age 69 ± 14.76 [33-95] years). In 32.6% (30/93) of examinations with HEUS the examination conditions were optimal and in 29.03% (27/93) when the HHUS was used. Of the examinations, 50.08% (31/61) were carried out by both examiners in the same patient position. Using HHUS, the following sensitivity and specificities (respectively) were found: pericardial effusion (73.68%; 96.97%), hemodynamically relevant effusion (50%; 97.67%), right heart strain (90,91%; 96,72%), arrest of the right ventricle (100%; 87,5%), limitation of left ventricular pump function (91.49%; 86.11%), wall movement disorders (WMD, 97.29%; 78.95%), aortic valve sclerosis (42.86%; 86.67%), aortic regurgitation (60%; 95%), mitral valve sclerosis (60%; 100%), mitral reguritation (66.67%; 82.86%), tricuspid valve regurgitation (48%; 81,48%). Measurements of the dimensions of pericardial effusion, the left ventricle, the left atrium and the left ventricular posterior wall each had a positive correlation between the examination with HHUS and HEUS (Κ = 0.45 to 0.91). The diameters determined by HHUS and HEUS for the septum and aortic root, however, correlated negatively (κ = -0.61 to -0.86).

CONCLUSIONS

The use of echoscopy in emergency and intensive care medicine is not inferior to HEUS for detecting defined cardiac pathologies.

Adoptability and accuracy of point-of-care ultrasound in screening for valvular heart disease in the primary care setting

PURPOSE

Despite continued efforts, a majority of patients with valvular heart disease (VHD) remain undiagnosed and untreated. This study aimed to assess the adoptability and accuracy of point-of-care handheld echocardiographic assessments (POCE) in the primary care setting.

METHODS

Eleven previously untrained primary care providers were trained to use the Vscan Extend (GE, WI) POCE to assess VHD, left ventricular function (LVEF), and major extra-cardiac findings. Their assessments were compared to those of three blinded expert readers. A total of 175 patients underwent POCE assessments which were evaluated using Kappa statistics (κ) together with their estimated standard error, p value, and 95% CI bounds.

RESULTS

Each patient had a mean of 3.3 ± 1.1 (±SD) assessments performed. Identical or nearly identical agreement between previously untrained primary providers and expert readers was evident for the diagnosis of tricuspid regurgitation, mitral regurgitation, pericardial effusion, and volume status. These agreements were strongest in apical long axis (κ = 1, p < 0.001) and parasternal long and short axis views (κ > =0.82 p < 0.001), though agreement remained robust in apical 4-chamber views (κ ≥ 0.76). The agreements in LVEF assessment were identical in the apical long axis view (κ = 1, p < 0.001) and robust in the remaining 3 views (κ > =0.66, p < 0.001). The assessments of aortic stenosis (parasternal/long, κ = 0.42, and parasternal/short, κ = 0.47, both p < 0.001) were weak in their agreement.

CONCLUSION

Compared to expert echocardiography readers, the untrained providers' use of POCE for VHD shows high user adoptability and diagnostic accuracies in the primary care setting.

Video clip training improved emergency medicine residents’ interpretation ability of visual ejection fraction

Background:

Information on cardiac contractility is very important in resuscitation of critically ill patients. However, the measurement of ejection fractions by echocardiography is very difficult to perform for non-cardiologists. We developed a video clip to train emergency medicine residents to measure visual ejection fraction and compared the improvement in their interpretation ability with that following the conventional training method.

Objectives:

Improvement of interpreting ability of vEF in short period.

Methods:

A total of 27 multicentre emergency medicine residents were recruited and divided into conventional training group (N = 13) and video clip training group (N = 14). Self-training was done for 1 week. Pre-test and post-test comprising 20 questions were used for evaluation, and scores and interpretation time were recorded.

Results:

The score of the video clip training group showed a statistically significant improvement in contrast to the conventional training group (the score of pre- and post-test, ±5% scoring method: correct answer; video clip training group, 5.4/20 to 10.4/20 ( p < 0.001) versus conventional training group, 5.8/20 to 6.7/20 ( p = 0.204)). Furthermore, there was a statistically significant reduction in the interpretation time (interpretation time of video clip training group, 417.7–358.8 s ( p = 0.005) versus conventional training group, 416.8–411.5 s ( p = 0. 497)).

Conclusion:

In the video clip training group, interpretation accuracy improved, and the interpretation time was shorter than that of the conventional training group. Based on these results, we conclude that improvement in the visual ejection fraction interpretation ability by emergency medicine residents can be expected.

Effect of Experience and Training on the Concordance and Precision of Strain Measurements

OBJECTIVES

This study sought to show the degree to which experience and training affect the precision and validity of global longitudinal strain (GLS) measurement and to evaluate the variability of strain measurement after feedback.

BACKGROUND

The application of GLS for the detection of subclinical dysfunction has been recommended in an expert consensus document and is being used with increasing frequency. The role of experience in the precision and validity of GLS measurement is unknown, as is the efficacy of training.

METHODS

Fifty-eight readers, divided into 4 groups on the basis of their experience with GLS, calculated GLS from speckle strain analysis of 9 cases with various degrees of image quality. Intraclass correlation coefficients (ICCs), mean difference, SD, and coefficient of variation (CV) were compared against the measurements of a reference group that had experience with >1,000 cases of strain measurement. Individualized feedback was distributed, and repeat measurements were performed by 40 readers. Comparisons with the baseline variation provided information about whether feedback was effective.

RESULTS

The ICC for GLS was significantly greater than that for ejection fraction regardless of image quality. Experience with strain measurement affected the concordance in strain values among the readers; the group with the highest level of experience showed significantly better ICC than those with no experience, although the ICC of the inexperienced readers was still very good (0.996 vs. 0.975; p = 0.0002). As experience increased, the mean difference, SD, and CV became significantly smaller. The CV of segmental strain analysis showed significant improvement after training, regardless of experience.

CONCLUSIONS

The favorable interobserver agreement of GLS makes it more attractive than ejection fraction for follow-up of left ventricular function by multiple observers. Although experience is important, the precision of GLS was high for all groups. Training appears to be of most value for the assessment of segmental strain.