Screening of Native Valvular Heart Disease Using a Pocket-Sized Transthoracic Echocardiographic Device

Validation of a hand-held ultrasound device in the evaluation of aortic stenosis

Hand-held ultrasound devices (HHUD) are increasingly used in routine clinical practice, though they lacked continuous (CW) Doppler capability until recent times. There is limited evidence on the utility of HHUD in assessing aortic stenosis (AS) in real-world settings. Our goal was to validate a new HHUD with CW Doppler assessing AS hemodynamic severity. An observational, single-center study at the Valdecilla University Hospital, Santander, Spain between October 2022 and August 2023 was conducted. Patients previously diagnosed with AS were consecutively recruited. Following a reference echocardiographic examination in the cardiac imaging laboratory by an experienced operator (American Society of Echocardiography, level III), a HHUD with CW Doppler (Kosmos, EchoNous™) was used by an operator with intermediate echocardiography experience (American Society of Echocardiography, level II). The focus was on measuring aortic transvalvular Doppler velocities. Agreement between the mean trans-aortic gradient (mAG) was assessed using the intraclass correlation coefficient (ICC) test. A total of 101 patients were included. The reference test obtained a mAG of 29 mmHg [19.8-42.2], while the HHUD test showed 27.2 mmHg [16.2-43.9]. A strong correlation was observed (r = 0.89), with an ICC value of 0.87 and no significant bias (1.61 ± 0.9). The HHUD demonstrated very good ability to identify severe AS (kappa = 0.81, 95% CI 0.68-0.94; global agreement 92.1%) and good agreement for moderate (kappa = 0.58; global agreement = 80.2%) and mild (kappa = 0.73; global agreement = 88.1%) AS. Agreement was lower in patients with obesity (ICC = 0.63), poor acoustic windows (ICC = 0.74), or atrial fibrillation (ICC = 0.74). The HHUD showed good agreement with standard echocardiography in assessing AS. While it slightly underestimated mAG, it was accurate enough to reliably quantify AS severity.

A Rare Case of Severe Mitral Stenosis Presenting As Cardiogenic Shock

We report a case of severe mitral stenosis (MS) in a 58-year-old female from Guyana. Though rheumatic MS continues to be less prevalent in third-world countries, it poses a significant threat as far as morbidity and mortality are concerned. The modern definition of "Third World" is used to classify countries that are poor or developing. Countries that are part of the "third world" are generally characterized by (1) high rates of poverty, (2) economic and/or political instability, and (3) high mortality. The standard method of diagnosing MS in patients has been established as transthoracic echocardiograms (TTE), along with pertinent historical and physical exam findings. Specifically, with TTE, criteria include a mitral valve area ≤1.5 cm2, severe left atrial enlargement, and elevated pulmonary artery systolic pressure >50 millimeters of mercury (mmHg). Once diagnosed with severe MS, treatment options for patients range from non-surgical percutaneous mitral balloon valvuloplasty to surgical mitral valve commissurotomy. In our case, she was a 58-year-old female with a past medical history of seizures of unknown etiology, not on any home medication regimen, presenting to the emergency department with shortness of breath, malaise, weight loss, and bilateral lower leg edema. Vitals were significant for tachycardia at 153 bpm, tachypnea at 24 breaths per minute, and saturating at 96% on room air. On the physical exam, there was an irregularly irregular rhythm, bilateral crackles at the bases, right upper quadrant tenderness to palpation, bilateral pitting edema, and no calf tenderness. Lab findings were significant for elevated brain natriuretic peptide, but three electrocardiograms were performed in the emergency department, all confirming the new onset of atrial fibrillation. A CT angiogram of the chest was performed, which ruled out pulmonary embolus but additionally found marked reflux of contrast noted within the inferior vena cava and hepatic veins, along with right atrial dilation reflective of right heart strain; additionally, mitral valve calcifications were noted. The cardiologist on duty confirmed the diagnosis using point-of-care ultrasound (POCUS) followed by TTE; the patient was rapidly transferred to a hospital with appropriate services for surgical management within the same day of arrival at the emergency department. This case highlights the importance of bedside POCUS as an additional diagnostic tool for cardiologists, along with pertinent history, physical examination findings, and laboratory findings. Proper utilization of POCUS can allow for the immediate diagnosis of severe pathologies and prevent the delay of appropriate treatment, as seen in our case. Wider adoption of POCUS practices as a part of the general initial evaluation of patients has not yet been recommended by the American Heart Association but can offer clinical benefit in morbidity/mortality with expedited progression to appropriate treatment.

Point-of-Care Ultrasound in Detection, Severity and Mechanism of Significant Valvular Heart Disease and Clinical Management

BACKGROUND

Early diagnosis of significant valvular heart disease (VHD) enables appropriate implementation of the best therapeutic strategy and follow-up. Cardiac auscultation remains suboptimal in early detection of VHD. The aim of this study was to evaluate the utility of point-of-care ultrasound (POCUS) for early detection of VHD and its severity.

METHODS

All consecutive patients with VHD who did not have a standard echocardiogram prior to first outpatient cardiology consultation underwent history and physical examination followed by POCUS study by an experienced physician in a general cardiology clinic from June 2017 to August 2022 at our institution. Subsequent standard transthoracic echocardiography (sTTE) was performed as the gold standard. Comparison was performed between POCUS and sTTE for the presence and severity of VHD. sTTE was performed by registered cardiac sonographers and interpreted by another cardiologist blinded to the POCUS results.

RESULTS

A total of 77 patients were studied (ge 72 ± 11 years, 58.4% males). A total of 89 significant valvular abnormalities were diagnosed. There were 39 (43.8%) cases of regurgitant VHD, 16 (18.0%) of stenotic VHD and 34 (38.2%) had evaluation for prosthetic valve function. The sensitivity (90.9%; 82.4%; 83.3%; 100%) and specificity (100%; 96.7%; 100%; 100%) were high for detecting ≥ moderate aortic regurgitation (AR), mitral regurgitation (MR), aortic stenosis (AS) and prosthetic valvular abnormality, respectively. The weighted κ coefficient between POCUS and sTTE for the assessment of ≥ moderate MR, AR and AS was 0.81 (95% CI, 0.65-0.97), 0.94 (95% CI, 0.84-1.00) and 0.88 (95% CI, 0.76-1.0), respectively, indicating excellent agreement.

CONCLUSIONS

POCUS can identify patients with significant VHD and may serve as a powerful screening tool for early detection of significant VHD in the outpatient clinical practice with downstream impact on clinical management of significant VHD.

Organization of Pediatric Echocardiography Laboratories: Impact of Sonographers on Clinical, Academic, and Financial Performance

Echocardiography has evolved the first-line imaging for diagnosis and management of pediatric and congenital heart disease all over the world. While it recognized as essential component of pediatric cardiac care delivery, organization of pediatric echocardiography services is very heterogeneous across the world, mainly related to significant differences in material and human resources in heterogeneous health care systems. In this paper, we focus on the role of pediatric sonographers, defined as expert technicians in pediatric echocardiography. While in some services sonographers are an essential part of the organizational structure, other laboratories operate only with physicians trained in echocardiography. The impact of sonographers on clinical, academic and financial performance will be discussed. Two organizational models (with and without sonographers) will be compared, and the advantages and disadvantages of each model will be evaluated. Different models of care provision are possible and decisions on organizational models need to be adjusted to the demands and available resources.