ABSTRACT
Varying numbers of scans are required by different professional bodies before focused cardiac ultrasound (FCU) competence is assumed. It has been suggested that innovation in the assessment of FCU competence is needed and that competency assessment needs to be more individualized. We report our experience of how the use of sequential testing may help personalize the assessment of FCU competence. DESIGN: This was a planned exploratory reanalysis of previously prospectively collected data. FCU was performed sequentially by an intensive care trainee and expert on the same patient. Assessment of left ventricular (LV) function by the trainee and expert was compared. Sequential testing methods were used in the analysis of this data to see if they could be used to help in the assessment of competence. Each trainee had completed a 38-hour teaching program and a logbook of 30 scans prior to enrollment. SETTING: Tertiary Australian not for profit private academic hospital. MEASUREMENTS AND MAIN RESULTS: Two hundred seventy paired echocardiograms were completed by seven trainees. For trainees to achieve greater than 90% accuracy in correctly assessing LV function when compared with an expert, a variable number of scans were required. This ranged from 13 to 25 (95% CI, 13-25) scans. Over the study period, the ability to correctly identify LV function was maintained, and it appeared there was no degradation in skill. CONCLUSIONS: Using the Sequential Probability Ratio Test demonstrates a variable number of scans were required to show greater than 90% accuracy in the assessment of LV function. As such, the use of sequential testing could help individualize competency assessments in FCU. Additionally, our data suggests that over a 6-month period, echocardiographic skill is maintained without any formal teaching or feedback. Further work assessing the utility of this method based on larger samples is required.
ABSTRACT
BACKGROUND: Suicide left ventricle is a well-documented phenomenon occurring after valve replacement, however, it is most commonly described in the mitral valve replacement (MVR) and transcatheter aortic valve replacement (TAVR) population. Cases within the surgical aortic valve replacement (SAVR) population usually resolve with optimal medical and interventional therapies. We describe a case of left ventricular suicide following SAVR presenting with persistent haemodynamic instability despite currently accepted medical and surgical therapies. CASE SUMMARY: A 62-year-old male with severe aortic stenosis presented for SAVR and a MAZE procedure. There were no significant signs of ventricular hypertrophy on preoperative transthoracic echocardiogram (TTE). Intraoperatively, there was mild chordal systolic anterior motion of the mitral valve (SAM) which only occurred when underfilled. During recovery in the intensive care unit, the patient's pulmonary arterial pressures were noted to rise with worsening cardiac output. Subsequent TTE showed severe dynamic left ventricular outflow tract (LVOT) obstruction secondary to SAM. Due to refractory medical management, an alcohol septal ablation was performed. Despite resolution of obstruction, the patient exhibited biochemical signs of systemic hypoperfusion, and thus veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was initiated. Following 72 h of VA-ECMO support, the patient was weaned with complete resolution of biochemical insults. He was subsequently discharged from the hospital without complication. DISCUSSION: Compared to the TAVR population, suicide ventricle post-SAVR is comparatively rare. Patients who exhibit persistent impaired cardiac output postoperatively should be investigated rapidly with echocardiography. Furthermore, resolution of a LVOT obstruction state from procedural intervention may not immediately follow with improved cardiac output, and may require further supportive management.
