A novel semiquantitative assessment of right ventricular systolic function with a modified subcostal echocardiographic view

Cardiac point-of-care ultrasound: Practical integration in the pediatric and neonatal intensive care settings

Cardiac point-of-care ultrasound (POCUS) is a technology increasingly leveraged at the bedside by pediatric critical care and neonatology providers to identify real-time hemodynamic pathophysiology. We present a framework for (1) identifying the scope of cardiac POCUS within the clinical practice setting, (2) standardizing views for protocolized hemodynamic assessment relevant to pediatric critical illness and (3) integrating POCUS findings for therapeutic guidance. Within the review, we also discuss practical strengths and limitations to image acquisition and interpretation within the varied cardiac POCUS views. Finally, we explore unique considerations within the neonatal population.    Conclusion: Cardiac POCUS is a technology and tool that reveals important real-time information at the bedside of the critically ill child and infant. Understanding strengths and limitations of cardiac POCUS views and protocolizing an approach to answer focused clinical questions provides a framework for training and translation to clinical care. What is Known: • Ultrasound technology is now ubiquitous among pediatric critical care and neonatology settings, and growing literature supports an expanded role in not only procedural but also diagnostic applications. • Cardiac POCUS influences provider perception of pathophysiology and changes clinical management. What is New: • Effective cardiac POCUS training and subsequent translation to clinical practice should improve when clinical questions and protocolized approaches to image acquisition are standardized within a specialty. • Cardiac POCUS views have strengths and limitations which must be recognized when assessing the hemodynamic profile of a child or neonate.

Alternative Cardiac Point-of-Care Ultrasound Views

Point of care ultrasound (POCUS) and critical care echocardiography (CCE) is increasingly being used in intensive care units (ICUs). POCUS and CCE may be limited in some ICU patients because of inadequate information from standard echocardiographic windows. At the same time, data from POCUS and CCE in ICU may be critical to managing patients with cardiorespiratory failure. Alternative echocardiographic views done at the bedside by ICU practitioners may yield additional information or replace the missing data from the standard views. Information obtained from multiple echocardiographic views should be integrated and interpreted within the patient's other clinical information.

Point-of-Care Echocardiography in the Difficult-to-Image Patient in the ICU: A Narrative Review

OBJECTIVES

The objective of this narrative review was to address common obstacles encountered in the ICU to acquiring quality and interpretable images using point-of-care echocardiography.

DATA SOURCES

Detailed searches were performed using PubMed and Ovid Medline using medical subject headings and keywords on topics related to patient positioning, IV echo contrast, alternative subcostal views, right ventricular outflow tract (RVOT) hemodynamics, and point-of-care transesophageal echocardiography. Articles known to the authors were also selected based on expert opinion.

STUDY SELECTION

Articles specific to patient positioning, IV echo contrast, alternative subcostal views, RVOT hemodynamics, and point-of-care transesophageal echocardiography were considered.

DATA EXTRACTION

One author screened titles and extracted relevant data while two separate authors independently reviewed selected articles.

DATA SYNTHESIS

Impediments to acquiring quality and interpretable images in critically ill patients are common. Notably, body habitus, intra-abdominal hypertension, dressings or drainage tubes, postoperative sternotomies, invasive mechanical ventilation, and the presence of subcutaneous emphysema or lung hyperinflation are commonly encountered obstacles in transthoracic image acquisition in the ICU. Despite these obstacles, the bedside clinician may use obstacle-specific maneuvers to enhance image acquisition. These may include altering patient positioning, respiratory cycle timing, expanding the subcostal window to include multilevel short-axis views for use in the assessment of RV systolic function and hemodynamics, coronal transhepatic view of the inferior vena cava, and finally point-of-care transesophageal echocardiography.

CONCLUSIONS

Despite common obstacles to point-of-care echocardiography in critically ill patients, the beside sonographer may take an obstacle-specific stepwise approach to enhance image acquisition in difficult-to-image patients.

The use of critical care echocardiography in peri-arrest and cardiac arrest scenarios: Pros, cons and what the future holds

Echocardiography is being increasingly deployed as a diagnostic and monitoring tool in the critically ill. This rise in popularity has led to its recommendation as a core competence in intensive care, with several training routes available. In the peri-arrest and cardiac arrest population, point of care focused echocardiography has the potential to transform patient care and improve outcomes. Be it via diagnosis of shock aetiology and reversibility or assessing response to treatment and prognostication. This narrative review discusses current and future applications of echocardiography in this patient group and provides a structure with which one can approach such patients.

Subcostal TAPSE measured by anatomical M-mode: prospective reliability clinical study in critically ill patients

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE), evaluated from a four-chamber apical view, is an echocardiographic parameter for the detection of right ventricular systolic dysfunction (RVD). We decided to assess the reliability of TAPSE measured from subcostal view (sTAPSE) by anatomical M-mode imaging (AMM) for evaluation of right ventricular systolic function and prediction of RVD in the critically ill patients by comparison with other echocardiographic parameters.

METHODS

We conducted an observational, prospective clinical study in 100 patients hospitalized in the intensive care unit. TAPSE, doppler tissue imaging-derived tricuspid lateral annular systolic velocity (DTI-S´ wave), two-dimensional fraction area change (2D FAC) and DTI-right ventricular index of myocardial performance (DTI-RIMP) were measured by transthoracic echocardiography. A subcostal four-chamber view was recorded for sTAPSE measurement. For that purpose, the cursor of AMM was aligned along the direction of the tricuspid lateral annulus movement and the amplitude of the movement was measured.

RESULTS

In a group of patients aged 64±16 years with a 31% prevalence of RVD we identified strong correlation between TAPSE and sTAPSE (r=0.963, P<0.001). sTAPSE correlated well with other measures of right ventricular systolic function (DTI-S´ wave: r=0.765; 2D FAC: r=0.701; DTI-RIMP: r=-0.661, P<0.001, respectively). The value of sTAPSE ≤15 mm predicted the presence of RVD defined by TAPSE with a sensitivity of 94.7% and specificity of 100.0%.

CONCLUSIONS

The sTAPSE measured by AMM in a population of critically ill patients has been found to be a reliable parameter of right ventricular systolic function and predicted RVD with high reliability.

Transthoracic Right Heart Echocardiography for the Intensivist

BACKGROUND

The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature.

MAIN

RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy.

CONCLUSION

The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.

Echocardiography for the Assessment of Pulmonary Hypertension and Congenital Heart Disease in the Young

While invasive assessment of hemodynamics and testing of acute vasoreactivity in the catheterization laboratory is the gold standard for diagnosing pulmonary hypertension (PH) and pulmonary vascular disease (PVD) in children, transthoracic echocardiography (TTE) serves as the initial diagnostic tool. International guidelines suggest several key echocardiographic variables and indices for the screening studies when PH is suspected. However, due to the complex anatomy and special physiological considerations, these may not apply to patients with congenital heart disease (CHD). Misinterpretation of TTE variables can lead to delayed diagnosis and therapy, with fatal consequences, or–on the other hand-unnecessary invasive diagnostic procedures that have relevant risks, especially in the pediatric age group. We herein provide an overview of the echocardiographic workup of children and adolescents with PH with a special focus on children with CHD, such as ventricular/atrial septal defects, tetralogy of Fallot or univentricular physiology. In addition, we address the use of echocardiography as a tool to assess eligibility for exercise and sports, a major determinant of quality of life and outcome in patients with PH associated with CHD.

Update on noninvasive imaging of right ventricle dysfunction in pulmonary hypertension

Pulmonary hypertension (PH) is a progressive disease affecting patients across the life span. The pathophysiology primarily involves the pulmonary vasculature and right ventricle (RV), but eventually affects the left ventricular (LV) function as well. Safe, accurate imaging modalities are critical for diagnosis, serial monitoring, and tailored therapy. While cardiac catheterization remains the conventional modality for establishing diagnosis and serial monitoring, noninvasive imaging has gained considerable momentum in providing accurate assessment of the entire RV-pulmonary axis. In this state-of-the-art review, we will discuss the most recent developments in echocardiography, magnetic resonance imaging, and computed tomography in PH evaluation from pediatric to adult population.

Subcostal TAPSE: a retrospective analysis of a novel right ventricle function assessment method from the subcostal position in patients with sepsis

Background

Tricuspid annular plane systolic excursion (TAPSE) is frequently used as an objective measure of right-ventricular dysfunction. Abnormal TAPSE values are associated with poor prognosis in a number of disease states; however, the measure is not always easy to obtain in the critically ill. The purpose of this study is to assess the feasibility and accuracy of using a subcostal view and TAPSE measurement as a measure of right-ventricular dysfunction. A secondary aim was to perform a pilot study to assess whether right-ventricular dysfunction was associated with adverse outcomes including mortality.

Results

Subcostal TAPSE corresponds well with TAPSE obtained from the apical window at low and moderate TAPSE values (mean difference 1.2 mm (CI 0.04–2.36; 100% data pairs < 3-mm difference for TAPSE < 19 mm; 92% had < 3 mm difference at TAPDE < 24 mm). Subcostal TAPSE is able to accurately discriminate between abnormal and normal TAPSE results (sensitivity 97.8%, specificity 87.5%). There was no association between right-ventricular (RV) dysfunction and 90-day mortality.

Conclusions

Subcostal TAPSE is a feasible and accurate alternative to conventional TAPSE from the apical view in critically ill patients. Further research is required to elucidate the relationship between RV dysfunction and outcomes in sepsis.

Echocardiographic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care

Proficiency in echocardiography and lung ultrasound has become essential for anesthesiologists and critical care physicians. Nonetheless, comprehensive echocardiography measurements often are time-consuming and technically challenging, and conventional 2-dimensional images do not permit evaluation of specific conditions (eg, systolic anterior motion of the mitral valve, pneumothorax), which have important clinical implications in the perioperative setting. M-mode (motion-based) ultrasonographic imaging, however, provides the most reliable temporal resolution in ultrasonography. Hence, M-mode can provide clinically relevant information in echocardiography and lung ultrasound-driven approaches for diagnosis, monitoring, and interventional procedures performed by anesthesiologists and intensivists. Although M-mode is feasible, this imaging modality progressively has been abandoned in echocardiography and is often underutilized in lung ultrasound. This article aims to comprehensively illustrate contemporary applications of M-mode ultrasonography in the anesthesia and critical care medicine practice. Information presented for each clinical application will include image acquisition and interpretation, evidence-based clinical implications in the critically ill and surgical patient, and limitations. The present article focuses on echocardiography and reviews left ventricular function (mitral annular plane systolic excursion, E-point septal separation, fractional shortening, and transmitral propagation velocity); right ventricular function (tricuspid annular plane systolic excursion, subcostal echocardiographic assessment of tricuspid annulus kick, outflow tract fractional shortening, ventricular septal motion, wall thickness, and outflow tract obstruction); volume status and responsiveness (inferior vena cava and superior vena cava diameter and respiratory variability [collapsibility and distensibility indexes]); cardiac tamponade; systolic anterior motion of the mitral valve; and aortic dissection.

The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research

PURPOSE

Many echocardiographic indices (or methods) for assessing right ventricular (RV) function are available, but each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was defined in each study.

METHODS

Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997 to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary studies were excluded. These studies' characteristics and RV indices reported were summarized.

RESULTS

Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite indices, many did not explain their choices.

CONCLUSIONS

TAPSE seemed to be the most popular index in the last 2-3 years. Many studies used combinations of indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV dysfunction amongst these studies.