Development of a National Echocardiography Quality Improvement Programme: insights into feasibility, uptake, and clinical utility.

AIMS: There are minimal data on methods to measure and improve quality in image interpretation when reporting cardiovascular imaging studies. We sought to identify the feasibility and clinical utility of a nationally implemented quality assurance (QA) process. METHODS AND RESULTS: A web-based platform was developed to administer a national QA module to 27 echocardiography departments within the UK. Three QA modules were delivered from 2011. The proportion of units using the QA module increased from 14 (52.2%) in the first module to 22 (81.5%) in the third module. There was no significant change in the proportion of correct answers between the first module (88.9%) and the third module (82.8%), P = 0.3. The number of echocardiographers with at least one incorrect answer increased from 16 (21.6%) in the first module to 54 (34%) in the third module, P = 0.03. Overall, in valvular heart disease cases there were 36 (10.6%) incorrect responses where qualitative assessment of the severity of valve dysfunction was tested compared with 4 (3.6%) incorrect responses where quantitative assessment of valve dysfunction was tested, P = 0.04. In chamber quantification cases, there were 36 (6.8%) incorrect responses where qualitative assessment of chamber function was tested compared with 3 (2.1%) incorrect responses where quantitative assessment of chamber function was tested, P = 0.04. CONCLUSION: The incorporation of national QA programme is feasible with rapid uptake. The platform allows comparison of an individual's interpretation skills against a reference standard which can be used as a method to identify inter-observer variability and as a training tool.

Echocardiographic assessment of pulmonary hypertension: standard operating procedure.

Patients with suspected pulmonary hypertension (PH) should be evaluated using a multimodality approach to ensure that they receive a correct diagnosis. The series of investigations required includes clinical evaluation, noninvasive imaging techniques and right heart catheterisation (considered to be the "gold standard" for the diagnosis of PH). Current guidelines recommend that a detailed echocardiographic assessment is performed in all patients with suspected PH. In this review we summarise a protocol adopted by the National Pulmonary Hypertension Centres of UK and Ireland and approved by the British Society of Echocardiography for the evaluation of these patients. The views and measurements described are recommended for diagnosis, assisting in prognosis and providing a noninvasive means of following disease progression or response to therapy.

The role of echocardiography in the management of atrial fibrillation.

Atrial fibrillation is the most common arrhythmia in clinical practice and is associated with significant mortality and morbidity due to stroke. Echocardiography plays a critical role in defining the clinical context of the arrhythmia and guiding management. Transoesophageal echocardiography is used to exclude intracardiac thrombus to facilitate early cardioversion. Emerging technologies such as catheter ablation and left atrial appendage occlusion have expanded the role of echocardiography such that it is essential to achieve a high standard of cardiac imaging to optimize patient outcomes.

The role of echocardiography in guiding management in dilated cardiomyopathy.

Dilated cardiomyopathy (DCM) is a common and malignant condition, which carries a poor long-term prognosis. Underlying disease aetiologies are varied, and often carry specific implications for treatment and prognosis. The role of echocardiography is essential in not only establishing the diagnosis, but also in defining the aetiology, and understanding the pathophysiology. This article therefore explores the pivotal role of echocardiography in the evaluation and management of patients with DCM.

The complete array of electrocardiogram abnormalities secondary to myocardial contusion in a single case.

Myocardial contusion is a complication of blunt thoracic injuries. Transthoracic echocardiography and electrocardiography (ECG) monitoring are important in suspected cases. We report a 54-year-old man, who sustained a number of injuries including blunt chest injury as a consequence of a road traffic accident. Electrocardiography monitoring over a 48 h period demonstrated sequential degrees of conduction system block coupled with a temporary cardio-version from persistent atrial fibrillation to sinus rhythm, suggesting coincident pulmonary vein contusion.

Echocardiography in the emergency assessment of acute aortic syndromes.

Acute aortic syndrome (AAS) is a collective term for several life-threatening acute aortic conditions: aortic dissection, intramural haematoma (IMH), penetrating atherosclerotic ulcer, and traumatic transection. Mortality from acute ascending aortic (type A) dissection increases rapidly immediately after presentation, reaching 1-2% per hour for the first 48 h. Early surgical intervention is recommended for type A aortic dissection and has been shown to improve outcome. Transthoracic echocardiography is an extremely valuable, often overlooked, clinical tool in diagnosing and assessing AAS in the emergency setting. Although diagnostic sensitivity is suboptimal, it is very useful in assessing potential high risk features or complications, such as pericardial effusion, and diagnosing potential differential conditions. A negative transthoracic echocardiography (TTE), however, does not exclude AAS. In patients with a high risk of type A dissection or IMH (identified clinically or by TTE), the safest and most rapid 'gold standard' investigation is transoesophageal echocardiography, ideally performed with the cardiac surgical team standing by. This is of particular importance in the haemodynamically unstable patient. Transoesophageal echocardiography, helical CT, and MRI have similar diagnostic accuracy and, when there is diagnostic uncertainty or no indication for immediate intervention, should be used according to clinical need, local availability, and expertise.

Quantitation of right ventricular volumes and ejection fraction by three-dimensional echocardiography in patients: comparison with magnetic resonance imaging and radionuclide ventriculography.

Three-dimensional echocardiography (3DE) provides volumetric measurements without geometric assumptions. Volume-rendered 3DE has been shown to be accurate for the measurement of right ventricular (RV) volumes in vitro and in animal studies; however, few data are available regarding its accuracy in patients. This study examined the accuracy of 3DE for quantitation of RV volumes and ejection fraction (EF) in patients, compared to magnetic resonance imaging (MRI) and radionuclide ventriculography (RNV). Twenty patients underwent MRI, gated equilibrium RNV, and 3DE using rotational acquisition from both the transesophageal and transthoracic approaches. RV volumes and EF were calculated from the 3DE data using multislice analysis (true Simpson's rule). RV volumes calculated by MRI (end-diastolic volume (EDV) 109.4 +/- 34.3 mls, end-systolic volume (ESV) 59.6 +/- 31.0 mls, and EF 47.7 +/- 17.1%) agreed closely with 3DE. For transesophageal echocardiography, EDV was 108.1 +/- 29.7 mls (r = 0.86, mean difference 1.3 +/- 17.8 mls); ESV was 62.5 +/- 23.8 mls (r = 0.85, mean difference 2.8 +/- 15.1 mls); and EF was 43.2 +/- 11.7% (r = 0.84, mean difference 4.5 +/- 9.7%). For transthoracic echocardiography, EDV was 107.7 +/- 27.5 mls (r = 0.85, mean difference 1.6 +/- 18.2 mls); ESV was 59.7 +/- 22.1 mls (r = 0.93, mean difference 3.2 +/- 19.6 mls); and EF was 45.2 +/- 11.5% (r = 0.86, mean difference 2.0 +/- 9.4%). There were close correlations, small mean differences and narrow limits of agreement between RNV-derived EF (43.4 +/- 12.1%) and both transesophageal (r = 0.95 mean difference 0.2 +/- 3.7%) and transthoracic 3DE (r = 0.95, mean difference 1.8 +/- 5.4%). Three-dimensional echocardiography is a promising new method of calculating RV volumes and EF, comparing well with MRI and RNV. The accuracy of transthoracic 3DE was comparable to that of the transesophageal approach. Three-dimensional echocardiography has the potential to be useful in the clinical assessment of RV disorders.

Abnormal myocardial strain rate in noncompaction of the left ventricle.

A 28-year-old woman presented in the second trimester of pregnancy with palpitations and left heart failure. Transthoracic echocardiography showed features consistent with isolated noncompaction of the left ventricle. Doppler tissue echocardiography with strain-rate imaging revealed unique appearances of paradoxical alternating bands of compression and expansion throughout systole and diastole. These features may be pathognomonic for this disease.