Abstract 15: The Use of Handheld Focused Cardiac Ultrasound (FoCUS) for EF Assessment at Parkland Memorial Hospital: A Quality Improvement Initiative With Novel Applications for Clinical Outcomes

2018 ◽  
Vol 11 (suppl_1) ◽  
Author(s):  
Samreen Raza ◽  
Rebecca Vigen ◽  
Susan Matulevicius
Keyword(s):  
Image Quality ◽  
Gold Standard ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Quality Improvement Initiative ◽  
Cardiac Ultrasound ◽  
Endocardial Border ◽  
Ventricular Ejection Fraction ◽  
Focused Cardiac Ultrasound ◽  
Patient Reported

Background: Focused cardiac ultrasound (FCU) has been used to answer clinical questions. Chemotherapy-related cardiotoxicity (CRR) is an entity that requires serial echocardiography. It is unknown whether FCU can be used to screen for CRR using advanced practice providers (APPs). The goal of this study is to determine if FCU can be used to reliably evaluate left ventricular ejection fraction (EF) by an APP to assess for CRR. Methods: The study was conducted at the Echo lab and the Oncology clinic. An Oncology APP was trained on the use of FCU and EF analysis. The APP was trained to obtained standard 2D views for EF assessment and on EF interpretation. The EF assessment was compared to sonographer echocardiogram on the same day. EF was assessed by a cardiologist and this was deemed to be the gold standard. The studies were all analyzed by two separate blinded cardiologists and the degree of correlation was analyzed. Linear regression modeling to analyze correlation between EF interpretation between all blinded observers and Bland Altman analysis was performed. Image quality was evaluated for all FCU images by a single blinded cardiologist and segmental endocardial border delineation was scored. Results: A total of 91 patients were scanned in Phase I of the study. The correlation coefficient between cardiologists was r=0.93. The correlation between cardiologist and APP were r=0.79 and 0.76 respectively. For the images obtained by the APP, the correlation between the APP and cardiologists were =0.83 and re=0.78. The correlation between APP and EF gold standard was r=0.77. The correlation between experienced cardiologists interpreting the FCU images was r=0.87. All images were determined to be interpretable. Conclusions: There was good correlation between cardiologists with respect to EF analysis. There was also good correlation between APP and cardiologists for EF analysis. Image quality from FCU was found to be good and acceptable for interpretation. This study demonstrates it is feasible to train an APP on obtaining images for EF analysis and they can be trained on EF interpretation with good correlation with experienced echocardiographers. We will evaluate outcomes associated with its use including delays to chemotherapy imposed by traditional echocardiography, cost to the health care system and patient-reported outcomes.

scholarly journals P736 Feasibility and accuracy of real-time automatic quantification of left ventricular ejection fraction by hand-held ultrasound device

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
A Hjorth-Hansen ◽  
M S Magelssen ◽  
G N Anderssen ◽  
T Graven ◽  
J O Kleinau ◽  
...  
Keyword(s):  
Image Quality ◽  
Ejection Fraction ◽  
Real Time ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Lv Function ◽  
Cardiac Ultrasound ◽  
Automatic Assessment ◽  
Automatic Quantification ◽  
Focused Cardiac Ultrasound

Abstract Funding Acknowledgements This study is perfomed with loan of hand-held devices and technical support by GE Ultrasound. The study was financed by NTNU and Levanger Hospital Background Automatic quantification of left ventricular (LV) ejection fraction (EF) by hand-held ultrasound devices (HUDs) may increase the benefit of focused cardiac ultrasound by inexperienced users. Automatic measurements of EF (autoEF) from 4-chamber (4Ch) recordings are available for real-time use. Image quality is of major importance for EF assessment, but the influence of automatic quantification of LV function by HUD is not evaluated. Purpose To evaluate the feasibility and accuracy of autoEF for real-time quantification of LV function by HUDs, and to assess the importance of image quality and the operators’ experience for the accuracy of the method. Methods Patients referred to a cardiac outpatient clinic with suspected heart failure (HF) were included. In total, 5 GPs, 3 nurses and 5 cardiologists performed HUD examinations. Each patient was examined by a nurse and a general practitioner (GPs) using a HUD. Immediately thereafter, a cardiologist performed echocardiographic reference examination and a HUD examination for autoEF. The GPs underwent six pre-study practical training days in addition to lectures. The nurses were familiar with focused cardiac ultrasound from their work at the outpatient HF clinic. AutoEF was measured in 4Ch view only. Reference EF was measured by the cardiologists using the biplane Simpson’s method. Another cardiologist blinded to the reference measurements and operators evaluated each HUD recording on technical and qualitative parameters using a scale from 1 (poor) to 6 (very good), and recommended to accept or reject the autoEF result. In total, 510 recordings of autoEF were available for analysis. Results 87 patients (46% women) with mean age of 67.5 years were examined. Mean BMI was 29 kg/m2, 95% CI (27.5, 30.2). 24 (30%) had atrial fibrillation. Of 510 recordings with autoEF measurements, 255 (50%) were rejected during evaluation and considered not eligible for clinical use. AutoEF by HUD and refEF was mean (SD) 52.6% (16.7) and 53.2% (7.3), respectively. Overall, the quality score for autoEF recordings was mean (SD) 4.4 (0.9). The highest mean score was 5.0 (SD 0.7) by the cardiologist and lowest for the GPs 4.0 (SD 0.9) (p < 0.001). The corresponding proportions of accepted autoEF measurements were 75% and 33%, respectively. The difference compared to reference were lowest in the accepted recordings (p < 0.001). The most important parameters for correct autoEF measurements were a properly assessed 4Ch view, a well visualized mitral annulus and the number of segments with visible endocardium (all p < 0.01), the latter being the overall most important parameter. Conclusion The feasibility of evaluation of real-time automatic assessment of LV EF by HUD was only moderate. In the hands of the least experienced the use of automatic LV EF was not of adequate quality compared to reference. Thus, sufficient training and good image quality is essential for automatic assessment of LV function by HUDs.

scholarly journals A pebble clogging a river: a case report of thrombosed coronary aneurysmal ectasia

2020 ◽  
Author(s):  
Akshar Jaglan ◽  
Tarek Ajam ◽  
Steven C Port ◽  
Tanvir Bajwa ◽  
A Jamil Tajik
Keyword(s):  
Acute Coronary Syndrome ◽  
Coronary Artery ◽  
Kawasaki Disease ◽  
Treatment Options ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Coronary Artery Ectasia ◽  
Ventricular Ejection Fraction ◽  
Coronary Syndrome ◽  
Patient Reported

Abstract Background Coronary artery ectasia (CAE) is a rare anomaly that can present at any age. Predisposing risk factors include Kawasaki disease in a younger population and atherosclerosis in the older generation. We present a unique case of the management of a young woman diagnosed with multivessel CAE with aneurysmal changes in the setting of acute coronary syndrome and subsequently during pregnancy. Case summary A 23-year-old woman presented with acute onset chest pain. Electrocardiogram revealed no ischaemic changes; however, troponin I peaked at 16 ng/mL (reference range 0–0.04 ng/mL). Echocardiogram showed apical dyskinesis with preserved left ventricular ejection fraction. Coronary angiography showed multivessel CAE along with significant thrombus burden in an ectatic lesion of the left anterior descending artery. Since the patient was haemodynamically stable, conservative management with dual antiplatelet therapy and anticoagulation was started. On follow-up, coronary computed tomographic angiogram illustrated resolution of the coronary thrombi and echocardiogram showed improvement to the apical dyskinesis. It was presumed that Kawasaki disease was the most likely aetiology of her disease. Subsequently the patient reported that, contrary to medical advice, she was pregnant, adding another layer of complexity to her case. Discussion Coronary artery ectasia can be discovered as an incidental finding or can present with an acute coronary syndrome. Management is challenging in the absence of randomized trials and large-scale data. Treatment options include medications, percutaneous intervention, and surgical revascularization. Close surveillance is required in these patients to assess progression of disease. Here we discuss treatment options during acute coronary syndrome and pregnancy.

scholarly journals P900 The Heart Model: Automated LVEF calculation in the real world

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
G Dhunnoo ◽  
A Mills ◽  
E F Lloyd ◽  
A Sabra ◽  
A Margulescu ◽  
...  
Keyword(s):  
Correlation Coefficients ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Heart Model ◽  
Altman Plot ◽  
Endocardial Border ◽  
Independent Observer ◽  
Ventricular Ejection Fraction ◽  
Bland Altman Plot ◽  
Chamber View

Abstract Background Heart Model (HM) is a proprietary, model-based algorithm for measurement of left ventricular ejection fraction (LVEF) in a 3D dataset acquired from an apical 4-chamber view by transthoracic echocardiography (TTE). There is evidence for superior reproducibility compared to 2D echo methods for LVEF measurement. Objective To assess the correlation of LVEF by HM with conventional, 2D LVEF methods. Methods All TTEs performed between 04-08/02/2019 by 2 HM-trained sonographers were included. Demographic characteristics, indication for TTE, LVEF by Simpson"s (LVEF_S), by "eyeballing" (LVEF_EB) and by HM (LVEF_HM), were recorded; LVEF for each study was also estimated by eye-balling by an experienced observer unaware of the reported LVEF (LVEF_IND). We compared LVEF by each method, their reciprocal correlations and their correlation with LVEF_HM. Image quality was rated excellent (endocardial border visible for all segments in the 3 apical views), good (< 1 segment was not visible / view), adequate (< 3 segments were not visible) and limited (<4 segments were not visible). Indications for TTE were: assessment of LVEF in 1/3 of the studies, murmurs in 1/5, and other indications in the rest. Results We included 74 patients (42 M, mean age (SD) 69.8(13.9), range 18-92 years). Forty-nine (66%) patients were in sinus rhythm, 23 (31%) were in AF, and the rest were in various paced rhythms. Fifty patients (68%) had excellent, good or adequate images. The EFs calculated by different methods are shown in the Table (p > 0.05 for all), an the Bland Altman plot (LVEF_EB vs HM) in the figure. LVEF_HM correlated modestly with the other methods if all studies were included (r = 0.535 LVEF_HM vs. LVEF_EB); the correlation improved if only good-quality studies were included (r = 0.769, p < 0.001 for both). All combinations of LVEF_IND, LVEF_EB and LVEF_S had correlation coefficients >0.93. Conclusions The Heart Model algorithm for LVEF measurement correlates well with traditional 2D methods in patients with good endocardial border definition, where its use can potentially improve reproducibility and reduce exam duration. LVEF by method (good-quality studies) N = 50 Simpson"s Eyeballing HeartModel Independent Mean(%) 48.6 48.9 50.9 48.8 SD(%) 17.8 16.6 14.9 15.7 Median(%) 54.5 52.5 53 50 Range(%) 16-74 17.5-72.5 19-88 15-75 SD - standard deviation Independent - LVEF estimate (eyeballing) by independent observer unaware of reported EFs. LVEF_EB was chosen as it was available inall the reports. Abstract P900 Figure. Bland Altman Plot (LVEF_EB vs LVEF_HM)

P3547Real world experience of sacubitril/valsartan: insights on tolerability and outcome from a specialised heart failure clinic

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
K C Neoh ◽  
D Rasoul ◽  
F Hunt ◽  
D W S Chong
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Nyha Class ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
National Database ◽  
Mineralocorticoid Receptor Antagonist ◽  
Ventricular Ejection Fraction ◽  
Reduced Ejection Fraction ◽  
Patient Reported

Abstract Background Sacubitril/Valsartan has been shown to improve symptoms and outcomes in patients with heart failure (HF) reduced ejection fraction in a single large randomised controlled trial. However, real-world data on its effect is limited. Purpose Our centre operates a dedicated HF clinic for the initiation and titration of Sacubitril/Valsartan in suitable patients. We report on patient tolerability and incidence of adverse effects. We also assessed change in New York Heart Association (NYHA) class and left ventricular ejection fraction (LVEF) post-treatment, as well as HF hospitalisation and mortality at 6 months. Methods We conducted a retrospective review of all patients seen in the clinic between January 2016 to January 2019. Patient demographics and pre-initiation treatments were recorded. We compared NYHA class and LVEF category as measured by echocardiography, at initiation and post-titration to the maximum tolerated dose. Data on HF admissions were obtained from electronic hospital records and mortality from a national database. Results A total of 179 patients were initiated on Sacubitril/Valsartan and included in the study. Mean age was 71 years (41–90), and 138 (77%) were male. Half of the patient cohort (89) had an ischaemic aetiology. Prior to initiation, all patients were established on an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Almost all were on a beta-blocker (99%) and mineralocorticoid receptor antagonist (98%). 56 patients (31%) had a Cardiac Resynchronisation Therapy (CRT) device and 31 (17%) had an Implantable Cardioverter-Defibrillator (ICD). Only 4 patients (2%) had to discontinue treatment completely due to an adverse reaction. Among them, 3 patients sustained an acute kidney injury (AKI) while 1 patient had increased breathlessness. 40 patients (22%) reported symptomatic hypotension which required dose reduction. 7 patients (4%) sustained an AKI. 2 patients reported a rash and 1 patient reported nausea. Figure 1 shows the change in NYHA class after establishment on Sacubitril/Valsartan. Data on change in LVEF post establishment of Sacubitril/Valsartan was available in 124 patients and is shown in figure 2. A total of 133 patients had completed titration of treatment by July 2018 and included in the analysis of 6-month outcome. 13 patients had one HF hospitalisation and all-cause mortality was 4.5% (6 patients). Only 1 patient had heart failure documented as the primary cause of death. Change in NYHA class and LVEF Conclusion In our cohort of well treated HF patients with reduced ejection fraction, 40% of patients experienced an improvement in NYHA class after establishment on Sacubitril/Valsartan while 35% of patients also experienced a significant improvement in LVEF. Treatment was well tolerated and the discontinuation rate was low when managed in a dedicated HF clinic focused on initiation of Sacubitril/Valsartan.

scholarly journals Does automated left ventricular ejection fraction assessment available on handheld ultrasound devices represent improvement in the diagnostic accuracy?

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
D Filipiak ◽  
JD Kasprzak ◽  
E Szymczyk ◽  
P Wejner-Mik ◽  
K Wdowiak-Okrojek ◽  
...  
Keyword(s):  
Left Ventricular Ejection Fraction ◽  
Image Quality ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Study Group ◽  
3D Image ◽  
Ventricular Ejection Fraction ◽  
Handheld Ultrasound ◽  
Apical View ◽  
The Difference

Abstract Funding Acknowledgements Type of funding sources: None. Purpose To assess the accuracy of an algorithm for automated measurement of the left ventricular ejection fraction (LVEF) available on handheld ultrasound device (HUD). Methods 112 patients admitted to the cardiology department, who were referred for the conventional echocardiographic examination, underwent additional assessment performed with HUD (Vscan Extend, GE Vingmed Ultrasound, Horten, Norway). In each case 4 – chamber apical view was obtained and LVEF was calculated by means of the LVivo software. Imaging quality was assessed in a 4-grade scale. Subsequently, during the examination performed with the use of the stationary echocardiograph the three-dimensional (3D) measurement of LVEF was recorded. Results Ultimately 96 (53 men, mean age 63 ± 11) patients were enrolled into the study group  In the remaining 16 cases (14%) 3D image quality was not sufficient to allow the calculation of the LVEF. LVivo software was unsuccessful in calculating LVEF in all these 16 patients and in additional 20 patients, who remained in the study group due to satisfactory 3D image quality. The quality of images acquired with the use of HUD was assessed as optimal in 25 (26%) patients, good in 37 (39%), acceptable in 24 (25%), poor in 10 (10%). The average LVEF value was 46%±14 with the 3D LVQ measurements and 48%±14 using the LVivo software. The correlation coefficient between  the LVEF values obtained with the two methods was  r = 0,92; (P < 0,0001). Using paired samples t-test we found that the difference between these two techniques was not significant (mean difference 4,5± 3,4%; P = 0,35). LVivo software EF assessment is based on a single apical view and for this reason we have assumed that the differences in EF can be larger in patients with regional wall motion abnormalities, in whom LVEF values derived from different apical views can significantly vary. For this reason the group of patients with history of myocardial infarction (40pts, 42%) was analysed separately and we found that the difference between LVivo and 3D LVEF was also not statistically significant (mean difference 6,1± 3,3%; P= 0,14). The correlation coefficient equalled  r = 0,78; (P < 0,0001). Conclusion The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality. Such expanded capabilities of HUDs can potentially lead to the overall improvements of the diagnostic accuracy of the ultrasonographic examinations, particularly when in hands of the non-expert echocardiographers.

Abstract 14082: The Effect of Diagnostic Ultrasound Mediated High Mechanical Impulses on Cardiac Output During an Ultrasound Enhancing Agent Infusion

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Swethika Sundaravel ◽  
Jessica Roettger ◽  
Arif Albulushi ◽  
Joan Olson ◽  
Feng Xie ◽  
...  
Keyword(s):  
Heart Rate ◽  
Cardiac Output ◽  
Contrast Echocardiography ◽  
Diagnostic Ultrasound ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Mechanical Index ◽  
Endocardial Border ◽  
Ventricular Ejection Fraction ◽  
The Impact

Introduction: Diagnostic ultrasound high mechanical index (MI) impulses are used during an ultrasound enhancing agent (UEA) infusion to improve endocardial border resolution and study myocardial perfusion. They have also been shown to cause endothelial shear, resulting in prolonged increases in ATP release and augment microvascular flow. The potential for these high MI impulses to alter cardiac output (CO) are unknown. Hypothesis: To study the impact of high MI impulses on CO Methods: Fifty one patients (mean age 63±15 years; 41% female) referred for contrast echocardiography underwent very low MI imaging with intermittent high MI impulses (1.6-1.7 Megahertz) in three different apical windows during either a Definity (Lantheus Medical) or Lumason (Bracco Diagnostics) infusion or bolus. CO was determined from Doppler measurements of left ventricular outflow tract stroke volume and heart rate. Mean contrast enhanced biplane left ventricular ejection fraction (LVEF) was 53±15%; (range 10-75%). CO from baseline without contrast (COwoC) and baseline after contrast (COwC) before high MI impulses were compared to CO after contrast and after high MI impulses (COaHMI). All CO measurements were made by an independent reviewer blinded to time of measurement (before or after high MI impulses). Results: Although heart rate did not change before and after intermittent high MI impulse administration, COaHMI increased significantly when compared to COwoC and COwC (p< 0.001 for both comparisons; Figure). In nine patients (18%), CO increased by more than 20%. In patients with LVEF < 40% COwC was 2.4±0.8 liters per minute (LPM) and COaHMI increased to 2.7± 0.8 LPM (p=0001). In patients with LVEF≥40%, COwC was 3.4±1.06 LPM while COaHMI increased to 3.8± 1.2 LPM (p=0.00001). Conclusions: Application of diagnostic guided high MI impulses during a commercially available microbubble infusion significantly increases CO irrespective of underlying left ventricular systolic function.

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