Safety and efficacy of physiologist-led dobutamine stress echocardiography
Keith Pearce and John Chambers
EDUCATIONAL SERIES ON THE SPECIALIST VALVE CLINIC: What is a valve clinic?
Sanjeev Bhattacharyya, Denise Parkin, and Keith Pearce
The prevalence of heart valve disease is increasing as the population ages. A series of studies have shown current clinical practice is sub-optimal. Some patients are referred for surgery at advanced stages of disease with impaired ventricular function or not even considered for surgery. Valve clinics seek to improve patient outcomes by providing an expert-led, patient-centred framework of care designed to provide an accurate diagnosis with active surveillance of valve pathology and timely referral for intervention at guideline directed trigger points. A range of different valve clinic models can be adopted depending on local expertise combining the skill set of cardiologist, physiologist/scientist and nurses. Essential components to all clinics include structured clinical review, echocardiography to identify disease aetiology and severity, patient education and access to both additional diagnostic testing and a multi-disciplinary meeting for complex case review. Recommendations for training in heart valve disease are being developed. There is a growing evidence base for heart valve clinics providing better care with increased adherence to guideline recommendations, more timely referral for surgery and better patient education than conventional care.
Impact of COVID-19 on UK stress echocardiography practice: insights from the EVAREST sites
Cameron Dockerill, William Woodward, Annabelle McCourt, Cristiana Monteiro, Elena Benedetto, Maria Paton, David Oxborough, Shaun Robinson, Keith Pearce, Mark J Monaghan, Daniel X Augustine, and Paul Leeson
Healthcare delivery is being transformed by COVID-19 to reduce transmission risk but continued delivery of routine clinical tests is essential. Stress echocardiography is one of the most widely used cardiac tests in the NHS. We assessed the impact of the first (W1) and second (W2) waves of the pandemic on the ability to deliver stress echocardiography.
Clinical echocardiography teams in 31 NHS hospitals participating in the EVAREST study were asked to complete a survey on the structure and delivery of stress echocardiography as well as its impact on patients and staff in July and November 2020. Results were compared to stress echocardiography activity in the same centre during January 2020.
24 completed the survey in July, and 19 NHS hospitals completed the survey in November. A 55% reduction in the number of studies performed was reported in W1, recovering to exceed pre-COVID rates in W2. The major change was in the mode of stress delivery. 70% of sites stopped their exercise stress service in W1, compared to 19% in W2. In those still using exercise during W1, 50% were wearing FFP3/N95 masks, falling to 38% in W2. There was also significant variability in patient screening practices with 7 different pre-screening questionnaires used in W1 and 6 in W2.
Stress echocardiography delivery restarted effectively after COVID-19 with adaptations to reduce transmission that means activity has been able to continue, and exceed, pre-COVID-19 levels during the second wave. Further standardization of protocols for patient screening and PPE may help further improve consistency of practice within the United Kingdom.
Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography
Liam Ring, Benoy N Shah, Sanjeev Bhattacharyya, Allan Harkness, Mark Belham, David Oxborough, Keith Pearce, Bushra S Rana, Daniel X Augustine, Shaun Robinson, and Christophe Tribouilloy
The guideline provides a practical step-by-step guide in order to facilitate high-quality echocardiographic studies of patients with aortic stenosis. In addition, it addresses commonly encountered yet challenging clinical scenarios and covers the use of advanced echocardiographic techniques, including TOE and Dobutamine stress echocardiography in the assessment of aortic stenosis.
British Society of Echocardiography Departmental Accreditation Standards 2019 with input from the Intensive Care Society
Sarah Ritzmann, Stephanie Baker, Marcus Peck, Tom E Ingram, Jane Allen, Laura Duffy, Richard P Steeds, Andrew Houghton, Andrew Elkington, Nina Bual, Robert Huggett, Keith Pearce, Stavros Apostolakis, Khalatabari Afshin, and the British Society of Echocardiography Departmental Accreditation and Clinical Standards Committees with input from the Intensive Care Society
This article sets out a summary of standards for departmental accreditation set by the British Society of Echocardiography (BSE) Departmental Accreditation Committee. Full accreditation standards are available at www.bsecho.org. The BSE were the first national organisation to establish a quality standards framework for departments that support the practice of individual echocardiographers. This is an updated version which recognises that, not only should all echocardiographers be individually accredited as competent to practice, but that departments also need to be well organised and have the facilities, equipment and processes to ensure the services they deliver are of an appropriate clinical standard. In combination with individual accreditation, departmental accreditation lays down standards to help ensure safe and effective patient care. These standards supersede the 2012 BSE Departmental Accreditation Standards. Standards are set to cover all potential areas of practice, including transthoracic (level 2) echocardiography, transoesophageal echocardiography, stress echocardiography, training, and emergency (level 1) echocardiography. The emergency echocardiography standard is a new addition to departmental accreditation and has been developed with input from the Intensive Care Society.
Echocardiographic assessment of the right heart in adults: a practical guideline from the British Society of Echocardiography
Abbas Zaidi, Daniel S Knight, Daniel X Augustine, Allan Harkness, David Oxborough, Keith Pearce, Liam Ring, Shaun Robinson, Martin Stout, James Willis, Vishal Sharma, and the Education Committee of the British Society of Echocardiography
The structure and function of the right side of the heart is influenced by a wide range of physiological and pathological conditions. Quantification of right heart parameters is important in a variety of clinical scenarios including diagnosis, prognostication, and monitoring response to therapy. Although echocardiography remains the first-line imaging investigation for right heart assessment, published guidance is relatively sparse in comparison to that for the left ventricle. This guideline document from the British Society of Echocardiography describes the principles and practical aspects of right heart assessment by echocardiography, including quantification of chamber dimensions and function, as well as assessment of valvular function. While cut-off values for normality are included, a disease-oriented approach is advocated due to the considerable heterogeneity of structural and functional changes seen across the spectrum of diseases affecting the right heart. The complex anatomy of the right ventricle requires special considerations and echocardiographic techniques, which are set out in this document. The clinical relevance of right ventricular diastolic function is introduced, with practical guidance for its assessment. Finally, the relatively novel techniques of three-dimensional right ventricular echocardiography and right ventricular speckle tracking imaging are described. Despite these techniques holding considerable promise, issues relating to reproducibility and inter-vendor variation have limited their clinical utility to date.
A minimum dataset for a Level 1 echocardiogram: a guideline protocol from the British Society of Echocardiography
Rakhee Hindocha, David Garry, Nadia Short, Tom E Ingram, Richard P Steeds, Claire L Colebourn, Keith Pearce, Vishal Sharma, and the Accreditation and Education Committees of the British Society of Echocardiography
The British Society of Echocardiography has previously outlined a minimum dataset for a standard transthoracic echocardiogram, and this remains the basis on which an echocardiographic study should be performed. The importance of ultrasound in excluding critical conditions that may require urgent treatment is well known. Several point-of-care echo protocols have been developed for use by non-echocardiography specialists. However, these protocols are often only used in specific circumstances and are usually limited to 2D echocardiography. Furthermore, although the uptake in training for these protocols has been reasonable, there is little in the way of structured support available from accredited sonographers in the ongoing training and re-accreditation of those undertaking these point-of-care scans. In addition, it is well recognised that the provision of echocardiography on a 24/7 basis is extremely challenging, particularly outside of tertiary cardiac centres. Consequently, following discussions with NHS England, the British Society of Echocardiography has developed the Level 1 echocardiogram in order to support the rapid identification of critical cardiac pathology that may require emergency treatment. It is intended that these scans will be performed by non-specialists in echocardiography and crucially are not designed to replace a full standard transthoracic echocardiogram. Indeed, it is expected that a significant number of patients, in whom a Level 1 echocardiogram is required, will need to have a full echocardiogram performed as soon as is practically possible. This document outlines the minimum dataset for a Level 1 echocardiogram. The accreditation process for Level 1 echo is described separately.
A patient-centred model to quality assure outputs from an echocardiography department: consensus guidance from the British Society of Echocardiography
Thomas E Ingram, Steph Baker, Jane Allen, Sarah Ritzmann, Nina Bual, Laura Duffy, Chris Ellis, Karina Bunting, Noel Black, Marcus Peck, Sandeep S Hothi, Vishal Sharma, Keith Pearce, Richard P Steeds, Navroz Masani, and the British Society of Echocardiography Clinical Standards and Departmental Accreditation Committees
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.
The EQF consists of four domains. These include assessment of Echo Quality (including study acquisition and report generation); Reproducibility & Consistency (including analysis of individual variability when compared to the group and focused clinical audit), Education & Training (for all providers and service users) and Customer & Staff 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.
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.
A practical guideline for performing a comprehensive transthoracic echocardiogram in adults: the British Society of Echocardiography minimum dataset
Shaun Robinson, Bushra Rana, David Oxborough, Rick Steeds, Mark Monaghan, Martin Stout, Keith Pearce, Allan Harkness, Liam Ring, Maria Paton, Waheed Akhtar, Radwa Bedair, Sanjeev Bhattacharyya, Katherine Collins, Cheryl Oxley, Julie Sandoval, Rebecca Schofield MBChB, Anjana Siva, Karen Parker, James Willis, and Daniel X Augustine
Since cardiac ultrasound was introduced into medical practice around the middle twentieth century, transthoracic echocardiography has developed to become a highly sophisticated and widely performed cardiac imaging modality in the diagnosis of heart disease. This evolution from an emerging technique with limited application, into a complex modality capable of detailed cardiac assessment has been driven by technological innovations that have both refined ‘standard’ 2D and Doppler imaging and led to the development of new diagnostic techniques. Accordingly, the adult transthoracic echocardiogram has evolved to become a comprehensive assessment of complex cardiac anatomy, function and haemodynamics. This guideline protocol from the British Society of Echocardiography aims to outline the minimum dataset required to confirm normal cardiac structure and function when performing a comprehensive standard adult echocardiogram and is structured according to the recommended sequence of acquisition. It is recommended that this structured approach to image acquisition and measurement protocol forms the basis of every standard adult transthoracic echocardiogram. However, when pathology is detected and further analysis becomes necessary, views and measurements in addition to the minimum dataset are required and should be taken with reference to the appropriate British Society of Echocardiography imaging protocol. It is anticipated that the recommendations made within this guideline will help standardise the local, regional and national practice of echocardiography, in addition to minimising the inter and intra-observer variation associated with echocardiographic measurement and interpretation.
British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab
Rebecca Dobson, Arjun K Ghosh, Bonnie Ky, Tom Marwick, Martin Stout, Allan Harkness, Rick Steeds, Shaun Robinson, David Oxborough, David Adlam, Susannah Stanway, Bushra Rana, Thomas Ingram, Liam Ring, Stuart Rosen, Chris Plummer, Charlotte Manisty, Mark Harbinson, Vishal Sharma, Keith Pearce, Alexander R Lyon, Daniel X Augustine, and the British Society of Echocardiography (BSE) and the British Society of Cardio-Oncology (BCOS)
The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.