Clinical-scientist-led transoesophageal echocardiography (TOE): using extended roles to improve the service.

At the North West Anglia NHS Foundation Trust, we perform transoesophageal echocardiography (TOE), a semi-invasive diagnostic test using ultrasound for high-quality heart imaging. TOE allows accurate diagnosis of serious heart problems to support high-quality clinical decision-making about treatment pathways. The procedure can be lengthy and is traditionally performed by a consultant cardiologist, who typically has multiple commitments. This constrains patient access to TOE, leading to waits from referral to test, delaying treatment decisions.In this quality improvement project, we improved access by redesigning workforce roles. The clinical scientist, who had been supporting the consultant during TOE clinics, took on performing the procedure as the main operator. We used the Model for Improvement to develop this clinical-scientist-led service-delivery model, and then test and refine it. This increased capacity and frequency of TOE clinics, reducing waits and releasing around 2 days per month of consultant time.Over five plan-do-study-act cycles, we tested six changes/refinements. Our targets were to reduce the maximum waiting time for TOE to 3 working days for inpatients and to 14 working days for outpatients. We succeeded, achieving reductions in mean waiting times from 7.7 days to 3.0 days for inpatients and from 33.2 days to 8.3 days for outpatients.TOE requires intubation; when this fails, TOE is abandoned. We believe light (rather than heavy) sedation is helpful for this intubation. We reduced sedation levels (from a median of 3 mg of midazolam to 1.5 mg) and, as a secondary outcome of this project, reduced the intubation failure rate from 13% to 0% (over 32 postchange patients).Following this project, our TOE service is usually performed by a clinical scientist in echocardiography who has British Society of Echocardiography TOE accreditation and advanced training. We have sustained the improved performance and demonstrated the value of enhanced roles for clinical scientists.

Left Atrial Function Is Associated with Earlier Need for Cardiac Surgery in Moderate to Severe Mitral Regurgitation: Usefulness in Targeting for Early Surgery.

BACKGROUND: The aim of this study was to determine whether assessment of left atrial (LA) function helps identify patients at risk for early deterioration during follow-up with mitral valve prolapse and mitral regurgitation. METHODS: Patients with moderate to severe mitral regurgitation but no guideline-based indications for surgery were retrospectively identified from a dedicated clinical database. Maximal and minimal LA volumes were used to derive total LA emptying fraction ([maximal LA volume - minimal LA volume]/maximal L volume × 100%). Average values of peak contractile, conduit, and reservoir strain were obtained using two-dimensional speckle-tracking imaging. The study outcome was time to mitral surgery. RESULTS: One hundred seventeen patients were included; median follow-up was 18 months. Sixty-eight patients underwent surgery. Receiver operating characteristic curves were used to derive optimal cutoffs for TLAEF (>50.7%) and strain (reservoir, >28.5%; contractile, >12.5%). Using Cox analysis, TLAEF and contractile, reservoir, and conduit strain were univariate predictors of time to event. After multivariate analysis, TLAEF (hazard ratio, 2.59; P = .001), reservoir strain (hazard ratio, 3.06; P < .001), and contractile strain (hazard ratio, 2.01; P = .022) remained independently associated with events, but conduit strain did not. Using Kaplan-Meier curves, event-free survival was considerably improved in patients with values above the derived thresholds (TLAEF: 1-year survival, 78 ± 5% vs 28 ± 8%; 3-year survival, 68 ± 6% vs 13 ± 5%; P < .001 for both; reservoir strain: 1-year survival, 79 ± 5% vs 29 ± 7%; 3-year survival, 67 ± 6% vs 15 ± 6%; P < .001 for both; contractile strain: 1-year survival, 80 ± 5% vs 41 ± 7%; 3-year survival, 69 ± 6% vs 24 ± 6%; P < .001 for both). CONCLUSION: LA function is independently associated with surgery-free survival in patients with mitral valve prolapse and moderate to severe mitral regurgitation. Quantitative assessment of LA function may have clinical utility in guiding early surgical intervention in these patients.

Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography.

Pulmonary hypertension is defined as a mean arterial pressure of ≥25 mmHg as confirmed on right heart catheterisation. Traditionally, the pulmonary arterial systolic pressure has been estimated on echo by utilising the simplified Bernoulli equation from the peak tricuspid regurgitant velocity and adding this to an estimate of right atrial pressure. Previous studies have demonstrated a correlation between this estimate of pulmonary arterial systolic pressure and that obtained from invasive measurement across a cohort of patients. However, for an individual patient significant overestimation and underestimation can occur and the levels of agreement between the two is poor. Recent guidance has suggested that echocardiographic assessment of pulmonary hypertension should be limited to determining the probability of pulmonary hypertension being present rather than estimating the pulmonary artery pressure. In those patients in whom the presence of pulmonary hypertension requires confirmation, this should be done with right heart catheterisation when indicated. This guideline protocol from the British Society of Echocardiography aims to outline a practical approach to assessing the probability of pulmonary hypertension using echocardiography and should be used in conjunction with the previously published minimum dataset for a standard transthoracic echocardiogram.