Merri L. Bremer

Echocardiography in the Management of Patients with Left Ventricular Assist Devices: Recommendations from the American Society of Echocardiography.

Raymond F. Stainback, MD, FASE, Chair, Jerry D. Estep, MD, FASE, Co-Chair, Deborah A. Agler, RCT, RDCS, FASE, Emma J. Birks, MD, PhD, Merri Bremer, RN, RDCS, EdD, FASE, Judy Hung, MD, FASE, James N. Kirkpatrick, MD, FASE, Joseph G. Rogers, MD, and Nishant R. Shah, MD, MSc, Houston, Texas; Cleveland, Ohio; Louisville, Kentucky; Rochester, Minnesota; Boston, Massachusetts; Philadelphia, Pennsylvania; and Durham, North Carolina

Impact of an Emergency Department Observation Unit Management Algorithm for Atrial Fibrillation

Background Atrial fibrillation (AF) is a common, growing, and costly medical condition. We aimed to evaluate the impact of a management algorithm for symptomatic AF that used an emergency department observation unit on hospital admission rates and patient outcomes. Methods and Results This retrospective cohort study compared 563 patients who presented consecutively in the year after implementation of the algorithm, from July 2013 through June 2014 (intervention group), with 627 patients in a historical cohort (preintervention group) who presented consecutively from July 2011 through June 2012. All patients who consented to have their records used for chart review were included if they had a primary final emergency department diagnosis of AF. We observed no significant differences in age, sex, vital signs, body mass index, or CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack) score between the preintervention and intervention groups. The rate of inpatient admission was significantly lower in the intervention group (from 45% to 36%; P<0.001). The groups were not significantly different with regard to rates of return emergency department visits (19% versus 17%; P=0.48), hospitalization (18% versus 16%; P=0.22), or adverse events (2% versus 2%; P=0.95) within 30 days. Emergency department observation unit admissions were 40% (P<0.001) less costly than inpatient hospital admissions of ≤1 days duration. Conclusions Implementation of an emergency department observation unit AF algorithm was associated with significantly decreased hospital admissions without increasing the rates of return emergency department visits, hospitalization, or adverse events within 30 days.

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 patients 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.

Relationship of Sonographer Credentialing to Intersocietal Accreditation Commission Echocardiography Case Study Image Quality

BACKGROUND Cardiac sonographer credentialing may guarantee baseline content knowledge but does not directly evaluate clinical scanning skills. The aim of this study was to determine the relationship of sonographer credentialing status to clinical competence, as defined by image quality of case studies submitted for Intersocietal Accreditation Commission (IAC) adult transthoracic echocardiography laboratory accreditation. METHODS In this study, data were retrieved retrospectively from the IAC Echocardiography application database for all adult echocardiography laboratories applying online from August 10, 2011, to December 12, 2013. Aortic stenosis (AS) and left ventricular (LV) regional dysfunction case studies were analyzed separately. Sonographers submitting case studies were coded as credentialed or noncredentialed. An image quality score (IQS) was calculated for each case study, reflecting review scores for examination components directly related to image quality and acquisition. The group of sonographers was divided into quartiles on the basis of annual procedure volume; mean case study IQS was compared between credentialed and noncredentialed sonographers. RESULTS For all four quartiles of the LV cases and the lowest three volume quartiles of the AS cases, mean IQS was significantly higher for credentialed than noncredentialed sonographers. Mean IQS in the highest volume quartile for AS studies was not significantly different by credential status. CONCLUSIONS In the setting of IAC Echocardiography accreditation, credentialed sonographers achieved higher mean IQSs than noncredentialed sonographers in seven of eight comparisons. However, further research will be required to expand the scope of this inference beyond AS and LV regional dysfunction cases submitted for IAC adult transthoracic echocardiography laboratory accreditation.

Association Between Echocardiography Laboratory Accreditation and the Quality of Imaging and Reporting for Valvular Heart DiseaseCLINICAL PERSPECTIVE

Background— It is presumed that echocardiographic laboratory accreditation leads to improved quality, but there are few data. We sought to compare the quality of echocardiographic examinations performed at accredited versus nonaccredited laboratories for the evaluation of valvular heart disease. Methods and Results— We enrolled 335 consecutive valvular heart disease subjects who underwent echocardiography at our institution and an external accredited or nonaccredited institution within 6 months. Completeness and quality of echocardiographic reports and images were assessed by investigators blinded to the external laboratory accreditation status and echocardiographic results. Compared with nonaccredited laboratories, accredited sites more frequently reported patient sex (94% versus 78%; P<0.001), height and weight (96% versus 63%; P<0.001), blood pressure (86% versus 39%; P<0.001), left ventricular size (96% versus 83%; P<0.001), right ventricular size (94% versus 80%; P=0.001), and right ventricular function (87% versus 73%; P=0.006). Accredited laboratories had higher rates of complete and diagnostic color (58% versus 35%; P=0.002) and spectral Doppler imaging (45% versus 21%; P<0.0001). Concordance between external and internal grading of external studies was improved when diagnostic quantification was performed (85% versus 69%; P=0.003), and in patients with mitral regurgitation, reproducibility was improved with higher quality color Doppler imaging. Conclusions— Accredited echocardiographic laboratories had more complete reporting and better image quality, while echocardiographic quantification and color Doppler image quality were associated with improved concordance in grading valvular heart disease. Future quality improvement initiatives should highlight the importance of high-quality color Doppler imaging and echocardiographic quantification to improve the accuracy, reproducibility, and quality of echocardiographic studies for valvular heart disease.

A Second Set of Eyes: Pre–Patient Dismissal Interpretation

Health care reimbursement in the United States is undergoing a significant shift from fee-for-service to value-based payment with the use of models based on bundles, episodes of care, and outcomes. Within this shift, challenges and opportunities exist for the field of cardiovascular ultrasound regarding how to define and provide high-quality diagnostic imaging that may be more directly linked to patient outcomes. Wiener observed that it is easier to measure the volume of cardiac imaging than its value, which typically focuses on how imaging affects patient care. During the American Society of Echocardiography Foundation Value-Based Healthcare Summit, it was noted that a challenge in defining cardiovascular ultrasound value is the existence of an often indirect link between the diagnostic test and patient outcomes. In addition, although a positive finding may lead to direct therapeutic intervention, the effect of negative test results that may eliminate or narrow differential diagnoses is harder to evaluate and may not always be considered when judging the value of cardiac imaging. Because of these challenges, quality efforts have traditionally focused on the procedural aspects of echocardiography. The American Society of Echocardiography advocates several measures to ensure a high-quality echocardiographic examination. These measures include, among others, adequate ultrasound equipment, competent technical skills, and consistent and complete image acquisition. As a result, study completeness is considered an essential component of a high-quality echocardiographic examination. Standard imaging protocols encompass the integration of twodimensional, color, and spectral Doppler modalities to provide comprehensive evaluation of cardiac disorders. However, a variety of additional images beyond the standard protocol may be needed for any given patient, so the protocol should be considered minimum criteria that may be inadequate without supplementation. Despite the imaging standards that have been proposed, incomplete echocardiographic studies still appear to be an issue. Recently, Nagueh et al. noted that one of the most frequent deficiencies resulting in delayed Intersocietal Accreditation Commission Echocardiography accreditation was incomplete studies that did not include required imaging components (32.7% of 2,020 laboratories). Furthermore, when Benavidez et al. examined diagnostic echocardiography errors at a large academic pediatric cardiac center, incomplete studies were noted to be a factor in 14% of diagnostic errors. Previous find-

Severe pulmonic valve regurgitation due to histoplasma endocarditis

Summary A 67-year-old man with myelodysplastic syndrome, disseminated histoplasmosis, and mitral valve replacement presented with dyspnea and peripheral edema. Transthoracic echocardiography demonstrated abnormal pulmonic valve with possible vegetation. Color flow imaging showed laminar flow from main pulmonary artery into right ventricular outflow tract (RVOT) in diastole. The continuous wave Doppler signal showed dense diastolic envelope with steep deceleration slope. These findings were consistent with severe pulmonic valve regurgitation, possibly due to endocarditis. Transesophageal echocardiography demonstrated an echodense mass attached to the pulmonic valve. The mitral valve bioprosthesis appeared intact. Bacterial and fungal blood cultures were negative; however, serum histoplasma antigen was positive. At surgery, the valve appeared destroyed by vegetations. Gomori methenamine silver-stains showed invasive fungal hyphae and yeast consistent with a dimorphic fungus. Valve cultures grew one colony of filamentous fungus. Itraconazole was continued based on expert infectious diseases diagnosis. After surgery, dyspnea and ankle edema resolved. To the best of our knowledge, histoplasma endocarditis of pulmonic valve has not been previously reported. Isolated pulmonic valve endocarditis is rare, accounting for about 2% of infectious endocarditis (IE) cases. Fungi account for about 3% of cases of native valve endocarditis. Characterization of pulmonary valve requires thorough interrogation with 2D and Doppler echocardiography techniques. Parasternal RVOT view allowed visualization of the pulmonary valve and assessment of regurgitation severity. As an anterior structure, it may be difficult to image with transesophageal echocardiography. Mid-esophageal right ventricular inflow–outflow view clearly showed the pulmonary valve and vegetation. Learning points Identification and characterization of pulmonary valve abnormalities require thorough interrogation with 2D and Doppler echocardiography techniques. Isolated pulmonary valve IE is rare and requires high index of suspicion. Histoplasma capsulatum IE is rare and requires high index of suspicion.