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Kai Neoh, Jamal N Khan, Khaled Albouaini and Adrian Chenzbraun
Sergio Barros-Gomes, Abdallah El Sabbagh, Mackram F Eleid and Sunil V Mankad
C Bleakley, M Eskandari, O Aldalati, K Moschonas, M Huang, A Whittaker and M J Monaghan
The mitral valve orifice area (MVOA) is difficult to assess accurately by 2D echocardiography because of geometric assumptions; therefore, 3D planimetry may offer advantages. We studied the differences in MVOA measurements between the most frequently used methods, to determine if 3D planimetry would result in the re-grading of severity in any cases, and whether it was a more accurate predictor of clinical outcomes.
This was a head-to-head comparison of the three most commonly used techniques to grade mitral stenosis (MS) by orifice area and to assess their impact on clinical outcomes. 2D measurements (pressure half-time (PHT), planimetry) and 3D planimetry were performed retrospectively on patients with at least mild MS. The clinical primary endpoint was defined as a composite of MV balloon valvotomy, mitral valve repair or replacement (MVR) and/or acute heart failure (HF) admissions.
Forty-one consecutive patients were included; the majority were female (35; 85.4%), average age 55 (17) years. Mean and peak MV gradients were 9.4 (4) mmHg and 19 (6) mmHg, respectively. 2D and 3D measures of MVOA differed significantly; mean 2D planimetry MVOA was 1.28 (0.40) cm2, mean 3D planimetry MVOA 1.15 (0.29) cm2 (P = 0.003). Mean PHT MVOA was 1.43 (0.44) cm2 (P = 0.046 and P < 0.001 in comparison to 2D and 3D planimetry methods, respectively). 3D planimetry reclassified 7 (17%) patients from mild-to-moderate MS, and 1 (2.4%) from moderate to severe. Overall, differences between the two methods were significant (X 2, P < 0.001). Only cases graded as severe by 3D predicted the primary outcome measure compared with mild or moderate cases (odds ratio 5.7).
3D planimetry in MS returns significantly smaller measurements, which in some cases results in the reclassification of severity. Routine use of 3D may significantly influence the management of MS, with a degree of prediction of clinical outcomes.
Keith Pearce and John Chambers
Victor Galusko, Owen Bodger and Adrian Ionescu
Hand-held imaging devices are widely used in clinical practice and are a useful tool. There is no published review examining the diagnostic parameters achieved with these devices in clinical practice.
We searched three online medical literature databases (PubMed, EMBASE and MEDLINE) for all literature published up until January 2018. We selected studies that (1) were conducted in the adult population; (2) used a truly hand-held device; (3) featured sensitivities and/or specificities on the use of the hand-held scanner. We extracted and summarised the diagnostic metrics from the literature.
Twenty-seven articles were excluded from the initial 56 relevant articles, as the device featured was not truly hand-held. Ultimately a total of 25 studies were analysed. Sixteen studies were carried out by experienced users, seven by users with little previous experience and two studies by nurses. High diagnostic parameters were achieved by all three groups when scanning cardiac pathology and intra-abdominal structures. Training of non-expert users varied, taking a mean of 21.6 h. These hand-held devices can change diagnoses at the bedside and be used as gate-keepers to formal echocardiography. Individual studies show them to be cost-effective.
Hand-held echocardiography is a useful tool in the hands of experts and novices alike. Studies conducted are highly heterogeneous making it difficult to pool data for the diagnostic metrics. Further studies with rigorous methodology are needed to evaluate the true diagnostic potential in the hands of non-experts and in the community as well as to validate training protocols.
Neil David Hauser and Justiaan Swanevelder
Transoesophageal echocardiography (TOE) has, in certain clinical situations, become an almost universal monitor and diagnostic tool. In the perioperative environment, TOE is frequently used to guide anaesthetic management and assist with surgical decision making for, but not limited to, cardiothoracic, major vascular and transplant operations. The use of TOE is not limited to the theatre environment being frequently used in outpatient clinics, emergency departments and intensive care settings. Two case reports, one of oesophageal perforation and another of TOE utilization in a patient having previously undergone an oesophagectomy, introduce the need for care while using TOE and highlight the need for vigilance. The safe use of TOE, the potential complications and the suggested contra-indications are then considered together with suggestions for improving the safety of TOE in adult and paediatric patients.
Sadie Bennett, Duwarakan Satchithananda and Gareth Law
A 42-year-old male was admitted with shortness of breath secondary to suspected heart failure and chest infection. An echocardiogram revealed a dilated and impaired left ventricle; ejection fraction 29%, with a large, mobile thrombus within the left ventricular apex. Due to the presence of liver dysfunction, vitamin K antagonists were deemed inappropriate; thus, the decision was taken to use the novel anticoagulation agent Apixaban. After 6 days of receiving Apixaban, a cardiac magnetic resonance scan was preformed, which showed complete resolution of the LV apical thrombus.
Patients with a dilated and impaired LV are at an increased risk of developing LV thrombus.
A large and mobile LV thrombus is associated with an increased risk of embolic events.
Vitamin K antagonists (VKAs) are often the first-line therapy for LV thrombus; however, these may be inappropriate in some patients.
NOACs are advantageous in comparison to VKAs and are used to treat: non-valvular atrial fibrillation, pulmonary embolisms and used in the prevention of recurrent deep vein thrombosis in adults.
To date, NOACs are not licensed for the treatment of an LV thrombus; however, there are growing evidence whereby there use has shown promise in reducing the risk of embolic events and demonstrate rapid reduction in size/full resolution of an LV thrombus.
Large, randomised research trials comparing NOACs and VKAs in the treatment of LV thrombus are needed, which may lead to a change in standard clinical practice that could benefit patients.
Peter Lee Luke, Christopher Eggett, Loakim Spyridopoulos and Tim Irvine
At present there are two recognised guidelines for the echocardiographic assessment of left ventricular diastolic function provided by the British Society of Echocardiography and American Society of Echocardiography/European Association of Cardiovascular Imaging. However, no direct comparison of these guidelines has been performed to establish whether they provide similar diastolic grading.
One hundred and eighty nine consecutive patients in sinus rhythm who underwent transthoracic echocardiography for a primary indication of either heart failure assessment or assessment of left ventricular systolic function were extracted from our database (McKesson Cardiology). Left ventricular diastolic function assessment was performed using both guidelines and the results compared. Chi-square, Kappa score and one-way ANOVA were used to evaluate the data at a level of p<0.05. The most frequent outcome was unclassifiable diastolic function with significantly more patients being labelled unclassified with the British compared to American guidelines (47.4% vs. 20.5% p<0.0001). Having excluded all unclassifiable patients, a significant difference still existed between the two guidelines with a higher proportion of grade one outcomes awarded by the ASE/EACVI guidelines When grading subcategories were individually compared there was significantly more grade one diastolic gradings awarded by American compared to the British guidelines (40.7% vs 20.1%, p<0.0001). In 47% of patients it was not possible to grade diastolic function using the British guidelines, compared to 21% using the American guidelines. For those patients where grading was possible, there was a significant difference in patients classified with normal and grade one diastolic function when using British and American guidelines.
The Echocardiography Quality Framework is a cohesive, patient-centered program, combining quality assurance and continuous service improvement, which can be adapted to suit the needs of any echocardiography department. The framework encompasses measures of the quality of care, reproducibility and consistency, education and training, and customer feedback. The EQF is scalable and adaptable to benefit any echocardiography service. A catalogue or library of supporting documents is being developed, drawing on expertise around the UK, to made available to any participating department. A mechanism and online infrastructure for national registration or assessment is being developed, to be used as a standalone adjunct or linked to BSE Departmental Accreditation. The principles that underpin the EQF may be applicable to other imaging disciplines and, ultimately, other medical or surgical specialties.
Tom E Ingram, Stephanie Baker, Jane Allen, Sarah Ritzmann, Nina Bual, Laura Duffy, Chris Ellis, Karina Bunting, Noel Black, Marcus Peck, Sandeep Singh Hothi, Vish Sharma, Keith Pearce, Richard P Steeds and Navroz Masani
Background: Quality assurance (QA) of echocardiographic studies is vital to ensure that clinicians can act on findings of high-quality to deliver excellent patient care. To date there is a paucity of published guidance on how to perform this QA. The British Society of Echocardiography (BSE) has previously produced an Echocardiography Quality Framework (EQF) to assist departments with their QA processes. This article expands on the EQF with a structured yet versatile approach on how to analyse echocardiographic departments to ensure high-quality standards are met. In addition, a process is detailed for departments that are seeking to demonstrate to external bodies adherence to a robust QA process.
Methods: The EQF consists of four domains. These include assessment of: Echo Quality (including study acquisition and report generation); Reproducibility and Consistency (including analysis of individual variability when compared to the group and focused clinical audit), Education and Training (for all providers and service-users) and Customer Satisfaction (of both service-users and patients/their carers). Examples of what could be done in each of these areas are presented. Furthermore, evidence of participation in each domain is categorised against a red, amber or green rating: with an amber or green rating signifying that a quantifiable level of engagement in that aspect of QA has been achieved.
Conclusion: The proposed EQF is a powerful tool that focuses the limited time available for departmental QA on areas of practice where a change in patient experience or outcome is most likely to occur.