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Duncan CF, Bowcock E, Pathan F, Orde SR. Mitral regurgitation in the critically ill: the devil is in the detail. Ann Intensive Care 2023; 13:67. [PMID: 37530859 PMCID: PMC10397171 DOI: 10.1186/s13613-023-01163-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/03/2023] [Indexed: 08/03/2023] Open
Abstract
Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.
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Affiliation(s)
- Chris F Duncan
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia.
| | - Emma Bowcock
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
| | - Faraz Pathan
- Department of Cardiology, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- Nepean Clinical School of Medicine, Charles Perkin Centre Nepean, University of Sydney, Kingswood, Sydney, NSW, 2747, Australia
| | - Sam R Orde
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
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2
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Fisher R, Zayan A, Gosling J, Ramos J, Nasr M, Garry D, Papachristidis A, Caetano F, Hopkins P. Serial image interpretation tasks improve accuracy and increase confidence in Level 1 echocardiography reporting: a pilot study. Echo Res Pract 2023; 10:6. [PMID: 37020250 PMCID: PMC10076813 DOI: 10.1186/s44156-023-00018-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Focused echocardiography is increasingly used in acute and emergency care, with point-of-care ultrasound integrated into several specialist training curricula (e.g. Emergency Medicine, Cardiology, Critical Care). Multiple accreditation pathways support development of this skill but there is scant empirical evidence to inform selection of teaching methods, accreditation requirements or quality assurance of education in focussed echocardiography. It has also been noted that access to in-person teaching can be a barrier to completing accreditation programmes, and that this may affect learners disproportionately depending on the location or nature of their institution. The purpose of the study was to determine whether serial image interpretation tasks as a distinct learning tool improved novice echocardiographers' ability to accurately identify potentially life-threatening pathology from focused scans. We also aimed to describe the relationship between accuracy of reporting and participants' confidence in those reports, and to assess users' satisfaction with a learning pathway that could potentially be delivered remotely. METHODS 27 participants from a variety of healthcare roles completed a program of remote lectures and 2 in-person study days. During the program they undertook 4 'packets' of 10 focused echocardiography reporting tasks (total = 40) based on images from a standardised dataset. Participants were randomized to view the scans in varying orders. Reporting accuracy was compared with consensus reports from a panel of expert echocardiographers, and participants self-reported confidence in their image interpretation and their satisfaction with the learning experience. RESULTS There was a stepwise improvement in reporting accuracy with each set of images reported, from an average reporting score of 66% for the 1st packet to 78% for the 4th packet. Participants felt more confident in identifying common life-threatening pathologies as they reported more echocardiograms. The correlation between report accuracy and confidence in the report was weak and did not increase during the study (rs = 0.394 for the 1st packet, rs = 0.321 for the 4th packet). Attrition during the study related primarily to logistical issues. There were high levels of satisfaction amongst participants, with most reporting that they would use and / or recommend a similar teaching package to colleagues. CONCLUSIONS Healthcare professionals undertaking remote training with recorded lectures, followed by multiple reporting tasks were capable of interpreting focused echocardiograms. Reporting accuracy and confidence in identifying life-threatening pathology increased with the number of scans interpreted. The correlation between accuracy and confidence for any given report was weak (and this relationship should be explored further given the potential safety considerations). All components of this package could be delivered via distance learning to enhance the flexibility of echocardiography education.
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Affiliation(s)
- Richard Fisher
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK.
| | - Amal Zayan
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Jennifer Gosling
- North-West London School of Anaesthesia / Pan-London School Intensive Care Medicine, London, UK
| | - Joao Ramos
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Mahmoud Nasr
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - David Garry
- Department of Critical Care, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Francisca Caetano
- Department of Critical Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Philip Hopkins
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
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Bennett S, Stout M, Ingram TE, Pearce K, Griffiths T, Duckett S, Heatlie G, Thompson P, Tweedie J, Sopala J, Ritzmann S, Victor K, Skipper J, Robinson S, Potter A, Augustine DX, Colebourn CL. Correction: Clinical indications and triaging for adult transthoracic echocardiography: a statement by the British Society of Echocardiography. Echo Res Pract 2023; 10:5. [PMID: 36895056 PMCID: PMC9999572 DOI: 10.1186/s44156-022-00014-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Affiliation(s)
- Sadie Bennett
- University Hospitals of North Midlands, Stoke‑on‑Trent, ST4 6QG, UK.
| | - Martin Stout
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Keith Pearce
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Simon Duckett
- University Hospitals of North Midlands, Stoke‑on‑Trent, ST4 6QG, UK
| | - Grant Heatlie
- University Hospitals of North Midlands, Stoke‑on‑Trent, ST4 6QG, UK
| | - Patrick Thompson
- Southern Health and Social Care Trust, Craigavon Area Hospital, Portadown, UK
| | - Judith Tweedie
- Southern Health and Social Care Trust, Craigavon Area Hospital, Portadown, UK
| | - Jo Sopala
- British Society of Echocardiography, London, UK
| | - Sarah Ritzmann
- Doncaster and Bassetlaw Teaching Hospitals, NHS Foundation Trust Doncaster Royal Infirmary, Doncaster, UK
| | | | - Judith Skipper
- Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | | | | | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,Department for Health, University of Bath, Bath, UK
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4
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Bennett S, Stout M, Ingram TE, Pearce K, Griffiths T, Duckett S, Heatlie G, Thompson P, Tweedie J, Sopala J, Ritzmann S, Victor K, Skipper J, Robinson S, Potter A, Augustine DX, Colebourn CL, Colebourn CL. Clinical indications and triaging for adult transthoracic echocardiography: a consensus statement by the British Society of Echocardiography in collaboration with British Heart Valve Society. Echo Res Pract 2022; 9:5. [PMID: 35820954 PMCID: PMC9277869 DOI: 10.1186/s44156-022-00003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/14/2022] [Indexed: 11/10/2022] Open
Abstract
Transthoracic echocardiography (TTE) is widely utilised within many aspects of clinical practice, as such the demand placed on echocardiography services is ever increasing. In an attempt to provide incremental value for patients and standardise patient care, the British Society of Echocardiography in collaboration with the British Heart Valve Society have devised updated guidance for the indications and triaging of adult TTE requests for TTE services to implement into clinical practice.
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Affiliation(s)
- Sadie Bennett
- University Hospitals of North Midlands, Stoke-on-Trent, ST4 6QG, UK.
| | - Martin Stout
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Keith Pearce
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Simon Duckett
- University Hospitals of North Midlands, Stoke-on-Trent, ST4 6QG, UK
| | - Grant Heatlie
- University Hospitals of North Midlands, Stoke-on-Trent, ST4 6QG, UK
| | - Patrick Thompson
- Southern Health and Social Care Trust, Craigavon Area Hospital, Portadown, UK
| | - Judith Tweedie
- Southern Health and Social Care Trust, Craigavon Area Hospital, Portadown, UK
| | - Jo Sopala
- British Society of Echocardiography, London, UK
| | - Sarah Ritzmann
- Doncaster and Bassetlaw Teaching Hospitals, NHS Foundation Trust Doncaster Royal Infirmary, Doncaster, UK
| | | | - Judith Skipper
- Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | | | | | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,Department for Health, University of Bath, Bath, UK
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McPhail E, Jahagirdar N, Walker N, Harris S, Monaghan M, Papachristidis A. The role of expert focus echocardiography during the COVID-19 pandemic. Echocardiography 2022; 39:701-707. [PMID: 35434786 PMCID: PMC9111758 DOI: 10.1111/echo.15351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/18/2022] [Accepted: 03/28/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Focus Echocardiography has routinely been used to offer quick diagnosis in critical care environments, predominantly by clinicians with limited training. During the COVID-19 pandemic, international guidance recommended all echocardiography scans were performed as focus studies to limit operator viral exposure in both inpatient and outpatient settings. The aim of this study was to assess the effectiveness of eFoCUS, a focus scan performed by fully trained echocardiographers following a minimum dataset plus full interrogation of any pathology found. METHODS All diagnostic echocardiograms, performed by fully trained echocardiographers during an 8-week period during the first UK COVID-19 wave, were included. The number of images acquired was compared in the following categories: admission status, COVID status, image quality, indication, invasive ventilation, pathology found, echocardiographer experience, and whether eFoCUS was deemed adequate to answer the clinical question. RESULTS In 87.4% of the 698 scans included, the operator considered that the eFOCUS echo protocol, with additional images when needed, was sufficient to answer the clinical question on the request. Echocardiographer experience did not affect the number of images acquired. Less images were acquired in COVID-19 positive patients compared to negative/asymptomatic (38 ± 12 vs. 42 ± 12, p = .001), and more images were required when a valve pathology was identified. CONCLUSION eFoCUS echocardiography is an effective protocol for use during the COVID-19 pandemic. It provides sufficient diagnostic information to answer the clinical question but differs from standard focus/limited protocols by enabling the identification and interrogation of significant pathology and incidental findings, preventing unnecessary repeat scans and viral exposure of operators.
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Affiliation(s)
- Eleanor McPhail
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Nishat Jahagirdar
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Nicola Walker
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Scott Harris
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Mark Monaghan
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
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Hothi SS, Jiang J, Steeds RP, Moody WE. Utility of Non-invasive Cardiac Imaging Assessment in Coronavirus Disease 2019. Front Cardiovasc Med 2021; 8:663864. [PMID: 34095253 PMCID: PMC8175983 DOI: 10.3389/fcvm.2021.663864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/29/2021] [Indexed: 12/20/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) was initially regarded as a disease of the lungs, which manifests as an acute respiratory illness and pneumonia, although more recently cardiac complications have been well-characterised. Serological cardiac biomarkers have been used to define acute myocardial injury, with significant elevation of high-sensitivity cardiac troponin (hs-cTn) associated with poor prognosis. Accordingly, 20-25% patients with acute myocardial injury (as defined by an elevated hs-cTn greater than the 99th percentile) have clinical signs of heart failure and increased mortality. An important outstanding clinical question is how best to determine the extent and nature of cardiac involvement in COVID-19. Non-invasive cardiac imaging has a well-established role in assessing cardiac structure and function in a wide range of cardiac diseases. It offers the potential to differentiate between direct and indirect COVID-19 effects upon the heart, providing incremental diagnostic and prognostic utility beyond the information yielded by elevated cardiac biomarkers in isolation. This review will focus on the non-invasive imaging assessment of cardiac involvement in COVID-19.
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Affiliation(s)
- Sandeep S. Hothi
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, United Kingdom
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jin Jiang
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, United Kingdom
| | - Richard P. Steeds
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - William E. Moody
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Moody WE, Mahmoud-Elsayed HM, Senior J, Gul U, Khan-Kheil AM, Horne S, Banerjee A, Bradlow WM, Huggett R, Hothi SS, Shahid M, Steeds RP. Impact of Right Ventricular Dysfunction on Mortality in Patients Hospitalized With COVID-19, According to Race. CJC Open 2021; 3:91-100. [PMID: 32984798 PMCID: PMC7502228 DOI: 10.1016/j.cjco.2020.09.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/17/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Epidemiologic studies suggest that Black, Asian, and minority ethnic (BAME) patients may be at risk of worse outcomes from coronavirus disease-2019 (COVID-19), but the pathophysiological drivers for this association are unknown. This study sought to investigate the relationship between findings on echocardiography, mortality, and race in COVID-19 pneumonia. METHODS This was a multicentre, retrospective, observational study including 164 adults (aged 61 ± 13 years; 78% male; 36% BAME) hospitalized with COVID-19 undergoing echocardiography between March 16 and May 9, 2020 at 3 days (interquartile range 2-5) from admission. The primary outcome was all-cause mortality. RESULTS After a median follow-up of 31 days (interquartile range 14-42 days), 66 (40%) patients had died. The right ventricle was dilated in 62 (38%) patients, and 58 (35%) patients had right ventricular (RV) systolic dysfunction. Only 2 (1%) patients had left ventricular (LV) dilatation, and 133 (81%) had normal or hyperdynamic LV systolic function. Reduced tricuspid annulus planar systolic excursion was associated with elevated D-dimer (ρ = -0.18, P = 0.025) and high-sensitivity cardiac Troponin (ρ = -0.30, P < 0.0001). Reduced RV systolic function (hazard ratio 1.80; 95% confidence interval, 1.05-3.09; P = 0.032) was an independent predictor of all-cause mortality after adjustment for demographic and clinical risk factors. Comparing white and BAME individuals, there were no differences in echocardiography findings, biomarkers, or mortality. CONCLUSIONS In patients hospitalized with COVID-19 pneumonia, reduced RV systolic function is prevalent and associated with all-cause mortality. There is, however, no racial variation in the early findings on echocardiography, biomarkers, or mortality.
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Affiliation(s)
- William E. Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - Hani M. Mahmoud-Elsayed
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - Jonathan Senior
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - Uzma Gul
- Department of Cardiology, Russells Hall Hospital, Dudley, United Kingdom
| | - Ayisha M. Khan-Kheil
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - Sebastian Horne
- Department of Cardiology, Russells Hall Hospital, Dudley, United Kingdom
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, United Kingdom
| | - William M. Bradlow
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - Robert Huggett
- Department of Cardiology, Russells Hall Hospital, Dudley, United Kingdom
| | - Sandeep S. Hothi
- Heart & Lung Centre, New Cross Hospital, Wolverhampton, United Kingdom
| | - Muhammad Shahid
- Department of Cardiology, Russells Hall Hospital, Dudley, United Kingdom
| | - Richard P. Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
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