Safety of Transesophageal Echocardiography in Patients with Thrombocytopenia.

BACKGROUND: According to current literature and guidelines, thrombocytopenia is considered a relative contraindication for performing transesophageal echocardiogram (TEE). In cancer patients, thrombocytopenia is frequently present. No prior studies have assessed the safety and complications of TEE in a thrombocytopenic population. METHODS: From January 2002 to December 2017, all patients who underwent TEE at MD Anderson Cancer Center in the nonoperative setting were included in the study. Patient characteristics, laboratory data, indications, and complications of TEE were obtained from medical records. Thrombocytopenia was defined as platelet count <100,000/µL prior to procedure. In this retrospective study, medical records were reviewed up to 30 days after procedure to search for possible complications related to TEE. RESULTS: During the study period, 2,345 TEE studies were performed. The mean age was 58.2 ± 15.3 years and 58.8% of patients were male. Thrombocytopenia was found in 814 patients (34.7%). More thrombocytopenic patients had hematologic malignancy, when compared with patients with normal platelet level (79.7% vs 30.2%; P < .001). The most common indication for TEE study was to evaluate for suspected endocarditis (48.0%) and was found more frequently in thrombocytopenic patients compared with those with normal platelet count (69.5% vs 36.5%; P < .001). Overall, 10 patients (0.4%) had complications related to TEE: eight minor oropharyngeal bleeding that did not require transfusion, one transient atrial fibrillation, and one esophageal perforation. There was no major bleeding, respiratory failure, or death related to TEE examination during the study period. Minor oropharyngeal bleeding was the only complication seen in thrombocytopenic patients (seven patients, 0.3%). CONCLUSIONS: Thrombocytopenia is common in cancer patients undergoing TEE. TEE-related complications are minimal in patients with both normal or low platelet count. With appropriate patient preparation and careful probe manipulation, TEE can be safely performed in thrombocytopenic patients.

Focused Cardiac Ultrasound by Nurses in Rural Vietnam.

BACKGROUND: Multiple studies investigating the use of focused cardiac ultrasound (FCU) in lower and middle-income countries and in medically underserved areas of the United States have demonstrated utility in echocardiographic screening algorithms performed by a variety of operators at different levels of training. No study to date has employed previously untrained nurses in a medically underserved setting to identify older adults with cardiac disorders. The aim of this study was to assess the accuracy of nurse-performed FCU to screen adult subjects at a village health center in Vietnam. METHODS: Vietnamese nurses (N = 8) underwent structured training conducted by sonographers and physicians during an outreach event sponsored by the American Society of Echocardiography Education and Research Foundation. The nurses were trained to detect abnormalities from a single echocardiographic view (parasternal long-axis) with a laptop-sized device and underwent pre- and posttraining testing. Following training, cardiac ultrasound examinations were performed on subjects >50 years of age at a village health center. First, the nurses performed focused cardiac ultrasound using two-dimensional and color Doppler imaging in the parasternal long-axis view using the M7 device and recorded their assessments. Two-dimensional color and spectral Doppler echocardiography was thereafter performed using the same machine by a sonographer (n = 5) or a Vietnamese echocardiography-trained cardiologist (n = 1). Interviews and electrocardiography were performed at the time of FCU. RESULTS: Each nurse improved from pre- to posttraining (average improvement in correct answers, 21%; range, 2%-31%). During the scanning phase, nurses' sensitivity, specificity, and accuracy for identifying subjects with any abnormality were 51.5% (85 of 165), 78.1% (82 of 105) and 61.9%, respectively. There were 60 subjects with significant findings (22.2%); all of these subjects had significant abnormalities visible on parasternal long-axis images. Overall sensitivity, specificity, and accuracy for identifying subjects with major abnormalities were 83.3% (50 of 60), 78.1% (164 of 210), and 78.6%, respectively. Nurse-performed FCU demonstrated much higher sensitivity with lower specificity than electrocardiography alone. The combination of nurse-performed FCU plus ECG identified all of the significant findings on echocardiography and increased accuracy to 91.5%. CONCLUSIONS: Nurses with no prior echocardiographic experience and with limited training can identify patients with significant cardiac abnormalities using FCU with acceptable accuracy. Screening strategies involving FCU may play a role in improving access to health care and triage in underserved areas.

Echocardiographic measures associated with the presence of left ventricular thrombus in patients with chemotherapy-related cardiac dysfunction.

BACKGROUND: Previous studies have not evaluated the prevalence and specific risk factors for the development of left ventricular (LV) thrombus in patients with severely reduced left ventricular dysfunction due to chemotherapy-related cardiomyopathy. We sought to evaluate the prevalence and potential markers of LV thrombus in this patient population. METHODS: From January 2009 to December 2013, patients with chemotherapy-related severe LV dysfunction (LV ejection fraction [LVEF] ≤ 30%) identified from MD Anderson Cancer Center database were reviewed. Patient characteristics and echocardiographic parameters were analyzed to determine potential risk factors for LV thrombus. RESULTS: A total of 121 patients met inclusion criteria (age 54.8 ± 15.2 years; female 63.6%; LVEF 26.3 ± 4%). LV thrombus was present in 9 patients (7.4%). Patients with LV thrombus have significantly lower LVEF compared to those without (18.7 ± 3.8% vs 26.9 ± 3.4%, P < .0001). Prevalence of LV thrombus increased as LVEF decreased and was the highest in patients with LVEF < 20%. By univariate analysis, decreased LVEF, particularly LVEF < 20% (OR 36.30, 95% CI 7.35-179.25, P < .0001) and restrictive LV filling pattern (OR 18.13, 95% CI 4.17-78.89, P = .0001) were associated with presence of LV thrombus. CONCLUSION: In patients with severely reduced LV systolic function due to chemotherapy-induced cardiomyopathy, LV thrombus was found in 7.4% of subjects. Severely decreased LVEF (<20%) and restrictive LV filling pattern were associated with the presence of LV thrombus.

Advanced Cardiovascular Sonographer: a proposal of the American Society of Echocardiography Advanced Practice Sonographer Task Force.

Echocardiographic examinations require a well-trained and competent sonographer to obtain proper anatomic and physiologic data to establish an accurate diagnosis for clinical decision-making and patient management. Although the formal education and training of cardiovascular sonographers are evolving, many entry-level and staff sonographers may not have sufficient practical or clinical knowledge of the necessary components of the echocardiographic study for the individual patient's clinical presentation. In many clinical settings, echocardiograms are read after the patient has left the laboratory. Thus, there is a role for a sonographer who can practice at an advanced level in a cardiovascular ultrasound laboratory to ensure a proper echocardiographic examination is performed on every patient. In this setting, an Advanced Cardiovascular Sonographer (ACS) would be able to review the indication for and quality of the examination. If additional images were needed, the ACS would assist the sonographer in obtaining these images, which would lead to the performance of a complete and fully diagnostic examination before the patient had left the echocardiography laboratory. In clinical practice, the quality of the examinations performed would improve, advancements in echocardiographic methods could be taught and incorporated into daily practice, and patients would be better served. The present report is a proposal from the American Society of Echocardiography Advanced Practice Task Force that identifies the potential of cardiac sonographers to achieve the ACS level.