COCATS 4 Task Force 5: Training in Echocardiography: Endorsed by the American Society of Echocardiography

Recommendations for Special Competency in Echocardiographic Guidance of Structural Heart Disease Interventions: From the American Society of Echocardiography

Transcatheter therapies for structural heart disease continue to grow at a rapid pace, and echocardiography is the primary imaging modality used to support such procedures. Transesophageal echocardiographic guidance of structural heart disease procedures must be performed by highly skilled echocardiographers who can provide rapid, accurate, and high-quality image acquisition and interpretation in real time. Training standards are needed to ensure that interventional echocardiographers have the necessary expertise to perform this complex task. This document provides guidance on all critical aspects of training for cardiology and anesthesiology trainees and postgraduate echocardiographers who plan to specialize in interventional echocardiography. Core competencies common to all transcatheter therapies are reviewed in addition to competencies for each specific transcatheter procedure. A core principle is that the length of interventional echocardiography training or achieved procedure volumes are less important than the demonstration of procedure-specific competencies within the milestone domains of knowledge, skill, and communication.

Effectiveness of Simulation-Based Training on Transesophageal Echocardiography Learning

Trial Registration

ClinicalTrials.gov Identifier: NCT05564507

The fundamental role of stress echo in evaluating coronary artery disease in specific patient populations

Stress echocardiography (SE) was initially used for assessing patients with known or suspected coronary heart disease by detecting and evaluating myocardial ischemia and viability. The implementation of SE has gradually been extended to several cardiovascular diseases beyond coronary artery disease, and SE protocols have been modified and adapted for the detection of coronary artery disease (CAD) or other cardiovascular diseases in specific patient populations. This review attempts to summarize current data concerning SE implementation and clinical value in these specific and diverse populations: patients with an intramural course of a coronary artery - known as a myocardial bridge, chronic severe or end-stage hepatic disease, chronic severe or end-stage kidney disease, cardiac allograft vasculopathy, patients scheduled for solid-organ transplantation and other intermediate and high-risk surgery and, finally, patients treated with anticancer drugs or radiotherapy.

Transesophageal echocardiography simulation: A review of current technology

Transesophageal echocardiography (TEE) has experienced tremendous increase in interest and demand alongside the rapid growth of transcatheter structural cardiac interventions. TEE instruction prolongs the procedure, increasing the risk of probe malfunction from overheating and patient complications from prolonged sedation. Echocardiographic simulation programs have been developed to hone the procedural skills of novice operators in a time-unrestricted, low-pressure environment before they perform TEEs on real patients. Simulators likely benefit training in interventional TEE for the same reasons. We searched PubMed, basic Google, and Google Scholar for currently marketed TEE simulators, including foreign as well as US companies. We queried the vendors regarding features of the simulators that pertain to effective instructional design for diagnostic TEE. We also queried regarding the simulators' applicability to training in interventional TEE. The vendors' responses are reported here. In addition, we discuss the specific training needs for structural heart interventions, for which echocardiographic simulation could be a powerful educational tool. Lastly, we discuss the role of simulation for formative and summative assessment, and the advances required to improve training in complex procedures within the field of interventional echocardiography.

[Focus ultrasound for cardiology practice. Russian consensus document]

This document is a consensus document of Russian Specialists in Heart Failure, Russian Society of Cardiology, Russian Association of Specialists in Ultrasound Diagnostics in Medicine and Russian Society for the Prevention of Noncommunicable Diseases. In the document a definition of focus ultrasound is stated and discussed when it can be used in cardiology practice in Russian Federation.

Rational and Design of the SIMULATOR Study: A Multicentre Randomized Study to Assess the Impact of SIMULation-bAsed Training on Transoesophageal echocardiOgraphy leaRning for Cardiology Residents

Introduction: Simulation-based training in transesophageal echocardiography (TEE) seems promising. However, data are limited to non-randomized or single-center studies. To assess the impact of simulation-based vs. traditional teaching on TEE knowledge and performance for medical residents in cardiology. Materials and Methods: Nationwide prospective randomized multicenter study involving 43 centers throughout France allowing for the inclusion of >70% of all French cardiology residents. All cardiology residents naive from TEE will be included. Randomization with stratification by center will allocate residents to either a control group receiving theoretical knowledge by e-learning only, or to an intervention group receiving two simulation-based training sessions on a TEE simulator in addition. Results: All residents will undergo both a theoretical test (0-100 points) and a practical test on a TEE simulator (0-100 points) before and 3 months after the training. Satisfaction will be assessed by a 5-points Likert scale. The primary outcomes will be to compare the scores in the final theoretical and practical tests between the two groups, 3 months after the completion of the training. Conclusion: Data regarding simulation-based learning in TEE are limited to non-randomized or single-center studies. The randomized multicenter SIMULATOR study will assess the impact of simulation-based vs. traditional teaching on TEE knowledge and performance for medical residents in cardiology, and whether such an educational program should be proposed in first line for TEE teaching.

Introducing echocardiography to medical students: A novel echocardiography E-Learning experience

BACKGROUND

Echocardiography is fundamental in the understanding of cardiology; however, echocardiography is not routinely taught in medical schools. The aim of this study is to assess whether teaching echocardiography to preclinical medical students using an e-learning software (ELS) is practical and appropriate.

METHODS

From 2017 to 2019, 1084 second-year medical students at Indiana University School of Medicine were introduced to echocardiography by using the ELS. In 2017 and 2018 students had a postcourse survey to assess echocardiography appropriateness and cardiology learning. Students in 2018 and 2019 were assessed for any association between the use of the ELS and learning cardiology by comparing examination scores.

RESULTS

In 2017-2018, 127 students responded to the survey (18% response rate). In 2017, 79% of responders and in 2018, 89% reported that introducing echocardiography to medical students is appropriate. In 2017, 78% and in 2018, 87% reported that it improved the understanding of cardiology. Student ELS usage was high for 2017-2018 (93% and 70%) but dropped in 2019 (30%). In 2018 and 2019, students who used ELS did statistically significantly better on the examination (total scores 84% vs. 82% (P = .008) in 2018; 84% vs. 81% (P = .002) in 2019).

CONCLUSIONS

Many 2nd year medical students felt learning echocardiography with ELS was appropriate and enhanced their learning cardiology. Using echocardiography to help learn cardiology appears to be supported with an association of ELS usage and improved examination scores. Our study suggests that echocardiography learning can and probably should begin in medical school.

Training, competence, and quality improvement in echocardiography: the European Association of Cardiovascular Imaging Recommendations: update 2020

The primary mission of the European Association of Cardiovascular Imaging (EACVI) is ‘to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging’. Echocardiography is a key component in the evaluation of patients with known or suspected cardiovascular disease and is essential for the high quality and effective practice of clinical cardiology. The EACVI aims to update the previously published recommendations for training, competence, and quality improvement in echocardiography since these activities are increasingly recognized by patients, physicians, and payers. The purpose of this document is to provide the general requirements for training and competence in echocardiography, to outline the principles of quality evaluation, and to recommend a set of measures for improvement, with the ultimate goal of raising the standards of echocardiographic practice. Moreover, the document aims to provide specific guidance for advanced echo techniques, which have dramatically evolved since the previous publication in 2009.

Sustainability and Versatility of the ABCDE Protocol for Stress Echocardiography

For the past 40 years, the methodology for stress echocardiography (SE) has remained basically unchanged. It is based on two-dimensional, black and white imaging, and is used to detect regional wall motion abnormalities (RWMA) in patients with known or suspected coronary artery disease (CAD). In the last five years much has changed and RWMA is not enough on its own to stratify patient risk and dictate therapy. Patients arriving at SE labs often have comorbidities and are undergoing full anti-ischemic therapy. The SE positivity rate based on RWMA fell from 70% in the eighties to 10% in the last decade. The understanding of CAD pathophysiology has shifted from a regional hydraulic disease to a systemic biologic disease. The conventional view of CAD encouraged the use of coronary anatomic imaging for diagnosis and the oculo-stenotic reflex for the deployment of therapy. This has led to a clinical oversimplification that ignores the lessons of pathophysiology and epidemiology, and in fact, CAD is not synonymous with ischemic heart disease. Patients with CAD may also have other vulnerabilities such as coronary plaque (step A of ABCDE-SE), alveolar-capillary membrane and pulmonary congestion (step B), preload and contractile reserve (step C), coronary microcirculation (step D) and cardiac autonomic balance (step E). The SE methodology based on two-dimensional echocardiography is now integrated with lung ultrasound (step B for B-lines), volumetric echocardiography (step C), color- and pulsed-wave Doppler (step D) and non-imaging electrocardiogram-based heart rate assessment (step E). In addition, qualitative assessment based on the naked eye has now become more quantitative, has been improved by contrast and based on cardiac strain and artificial intelligence. ABCDE-SE is now ready for large scale multicenter testing in the SE2030 study.

Isolated Tricuspid Regurgitation and Long-Term Outcome in Patients With Preserved Ejection Fraction

Background: The aim of this study was to evaluate the association of isolated tricuspid regurgitation (TR) with long-term outcome in patients with preserved left ventricular ejection fraction (LVEF).

Methods and Results: We retrospectively analyzed 3,714 patients who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in a hospital-based population, after excluding severe and moderate left-side valvular disease and LVEF <50%. We classified patients into 2 groups: moderate to severe TR (n=53) and no moderate to severe TR (n=3,661). Next, we generated a propensity score (PS)-matched cohort: the moderate to severe TR group and the no moderate to severe TR group (n=41 in each group). The primary outcome was a composite of all-cause death and major adverse cardiac events. In the moderate to severe TR group, patients were older, and more likely to have higher left atrial volume index and E/e’ than those in the no moderate to severe TR group. In the PS-matched cohort, cumulative 3-year incidence of the primary outcome was 61.5% in the moderate to severe TR group and 24.3% in the no moderate to severe TR group (log-rank P=0.043; hazard ratio, 2.86; 95% CI: 1.37–6.37).

Conclusions: Isolated moderate to severe TR is associated with poor clinical outcome in patients with preserved LVEF.

Utility of expert focused cardiac ultrasound in paediatric cardiology outreach clinics

OBJECTIVE

This prospective observational study evaluates the utility of expert focused cardiac ultrasound (eFCU) with spectral Doppler to inform decision making in established patients with specific, selected congenital cardiac defects in outreach clinics. Secondary objectives include determining if the addition of eFCU expands capacity in paediatric cardiology outreach clinics and if it improves the patient experience.

METHODS

Patients aged 2 months to 19 years old with a diagnosis of ventricular septal defect, atrial septal defect, atrioventricular septal defect, patent ductus arteriosus, aortic valve stenosis, or pulmonary valve stenosis with the need for follow-up echocardiography in an outreach clinic from August 2017 to June 2018 were studied. A novel assessment tool was used to determine the success of eFCU.

RESULTS

Forty-two patients from 11 clinics underwent eFCU with one unsuccessful exam making the failure rate 2.3% (95% CI 0.0006-0.1256). Addition of eFCU led to a significant increase in volume of patients able to be seen 19 versus 15.5 (p < 0.01). A majority of parents/patients reported a positive experience with eFCU.

CONCLUSION

Expert focused cardiac ultrasound with spectral Doppler can be used successfully for follow-up in patients with select CHD and the addition of eFCU permits increased patient capacity in outreach clinics and has the potential to improve the patient experience.

Handheld Ultrasound and Focused Cardiovascular Echography: Use and Information

The availability of miniaturized ultrasound machines has changed our approach to many cardiovascular diseases. Handheld ultrasound imaging can be performed at the bedside, it is easy to use, and the information provided, although limited, is of unquestionable importance for a quick diagnosis that leads to early treatment. They have unique characteristics: Low cost, wide availability, safety, accuracy, and can be used in different clinical scenarios and by operators with different backgrounds. Image acquisition and interpretation is rapid and provides, in each situation, useful information for diagnosis, prognosis, and clinical and therapeutic management. This review focuses on the use of handheld ultrasound devices, describes differences with other equipment, their limitations, and the numerous advantages derived from their use.

Defining the Role of Point-of-Care Ultrasound in Cardiovascular Disease

Echocardiography is the foundation for diagnostic cardiac testing, allowing for direct identification and management of various conditions. Point-of-care ultrasound (POCUS) has emerged as an invaluable tool for bedside diagnosis and management. The objective of this review is to address the current use and clinical applicability of POCUS to identify, triage, and manage a wide spectrum of cardiac conditions. POCUS can change diagnosis and management decisions of various cardiovascular conditions in a range of settings. In the outpatient setting, it is used to risk stratify and diagnose a variety of medical conditions. In the emergency department (ED) and critical care settings, it is used to guide triage and critical care interventions. Furthermore, the skills needed to perform POCUS can be taught to noncardiologists in a way that is retained and allows identification of normal and grossly abnormal cardiac findings. Various curricula have been developed that teach residents and advanced learners how to appropriately employ point-of-care ultrasound. In conclusion, POCUS can be a useful adjunct to the physical exam, particularly in critical care applications.

Prospective evaluation of cardiac ultrasound performance by general internal medicine physicians during a 6-month faculty development curriculum

Background

Point-of-care (POCUS) education is rapidly expanding within medical schools and internal medicine residency programs, but lack of trained faculty is a major barrier. While POCUS training can improve short-term outcomes, knowledge and skills rapidly decay without deliberate practice and feedback. The purpose of this study was to evaluate the performance of focused cardiac ultrasound (FCU) by volunteer general internal medicine (GIM) faculty participating in a longitudinal POCUS curriculum.

Methods

Participants: Nine GIM clinician-educators participated in a 6-month POCUS curriculum. Faculty performance was compared to three cardiology fellows. Three diagnostic cardiac sonographers (DCS) were also evaluated and served as the gold standard. Evaluation: the primary outcome was a FCU efficiency score, calculated by dividing image quality score by exam duration. FCU exams were conducted on three standardized patients after completion of an introductory workshop, at 3 months, and at 6 months. Two blinded cardiologists scored the exams. Analysis: mean efficiency scores were compared using a linear mixed effects model, followed by pairwise comparisons using Tukey’s test.

Results

GIM faculty’s FCU efficiency scores were maintained over the 6-month period (2.2, SE 1.0 vs. 3.8, SE 1.0, p = 0.076). Their scores at each session were similar to cardiology fellows (p > 0.69), but inferior to DCSs (p < 0.0001).

Conclusion

GIM faculty participating in a POCUS curriculum maintained their FCU performance over 6 months with efficiency scores comparable to experienced cardiology fellows.

Electronic supplementary material

The online version of this article (10.1186/s13089-018-0090-7) contains supplementary material, which is available to authorized users.

A quality control exercise in the echo laboratory: Reduction in inter-observer variability in the interpretation of pulmonary hypertension

BACKGROUND

Right ventricular systolic pressure (RVSP) estimated by echocardiography is critical for the initial screening and follow-up of pulmonary hypertension (PH). Inter-observer variability (IOV) in RVSP can impact clinical decision making. This study assessed whether a simple guideline-based teaching intervention could reduce the IOV in RVSP interpretation.

METHODS AND RESULTS

Eleven participants in a high-volume tertiary level echocardiography laboratory underwent an assessment of the baseline IOV in the assessment of RVSP for a series of transthoracic echocardiograms (TTE), depicting various degrees of PH among 8 cases each before and after a teaching intervention. The inter-observer variance (root-mean-square error) decreased from 26.0 mm Hg² (5.1 mm Hg) at baseline to 5.8 mm Hg² (2.4 mm Hg) post-teaching intervention (P = .025). The corresponding inter-class coefficient (ICC) increased from 0.89 to 0.98. Several factors relating to image acquisition and interpretation were identified as contributing to IOV in RVSP. The outcome was the development of a practical tool to mitigate these factors.

CONCLUSIONS

A simple structured teaching intervention successfully reduced IOV in the measurement of RVSP in a high-volume echo laboratory.

Speckle tracking echocardiography in the critically ill: enticing research with minimal clinical practicality or the answer to non-invasive cardiac assessment?

Echocardiography is developing rapidly. Speckle tracking echocardiography is the latest semi-automatic tool that has potential to quantitatively describe cardiac dysfunction that may be unrecognised by conventional echocardiography. It is a non-Doppler, angle-independent, feasible and reproducible method to evaluate myocardial function in both non-critically ill and critically ill populations. Increasingly it has become a standard measure of both left and right ventricle function in specific patient groups, e.g. chemotherapy-induced cardiomyopathy or pulmonary hypertension. To date there are few studies in the critically ill, predominantly in sepsis, yet all describe dysfunction beyond standard measures. Other areas of interest include heart-lung interactions, right ventricle function and twist and torsion of the heart. A word of caution is required, however, in that speckle tracking echocardiography is far from perfect and is more challenging, particularly in the critically ill, than implied by many published studies. It takes time to learn and perform and most values are not validated, particularly in the critically ill. We should be cautious in accepting that the latest software used in cardiology cohorts will automatically be the answer in the critically ill. Even with these limitations the technology is enticing and results fascinating. We are uncovering previously undescribed dysfunction and although it currently is essentially a research-based activity, there is great promise as a clinical tool as echocardiography analysis becomes more automated, and potentially speckle tracking echocardiography could help describe cardiac function in critical illness more accurately than is possible with current techniques.

Strain Imaging with a Bull's-Eye Map for Detecting Significant Coronary Stenosis during Dobutamine Stress Echocardiography

BACKGROUND

Accurate visual assessment of wall motion during dobutamine stress echocardiography (DSE) requires expertise; strain stress echocardiography thus has potential for the objective and reliable evaluation of stress-induced wall motion abnormalities. The aim of this study was to test the hypothesis that strain imaging also requires expertise. Diagnostic accuracy for significant coronary artery disease was compared between visual and strain analysis with a bull's-eye map, and the effect of expertise on readers' accuracy during DSE was determined.

METHODS

Thirty-seven patients who underwent both DSE and coronary angiography within 6 months were retrospectively selected. Three experts and two fellows performed visual and two-dimensional speckle-tracking analysis using vendor-dependent (GE) software in three apical views. A bull's-eye map of longitudinal strain and a postsystolic shortening map were generated at baseline and peak stress. Significant coronary stenosis was defined as a >1% reduction in longitudinal strain with an increase in postsystolic shortening of at least two contiguous segments in the specific coronary artery territory at peak stress compared with baseline.

RESULTS

Twenty-five patients had significant coronary artery disease (>70% stenosis on coronary angiography), including 17 with left anterior descending coronary artery stenosis and 19 with non-left anterior descending coronary artery stenosis. Overall, strain imaging provided no additional benefit over visual analysis in detecting significant stenosis per patient and per vessel among experts and fellows. Strain analysis by the fellows had significantly lower specificity and accuracy compared with the experts.

CONCLUSIONS

Expertise affects strain evaluation for detecting significant coronary artery disease during DSE.