Category Archives: Echocardiography

Advanced echo: Right Ventricular function #LIVES2017

Prof Anthony McLean from the Nepeam in Sydney delivered this excellent masterclass using a case from his unit as an example.

Assessing RV function using echocardiography is not easy- the gold standard is MRI https://t.co/CcJ0nBrDTP

There are a number of tools available to us as echocardiographers to monitor RV function:

Wall motion

RV:LV ratio https://t.co/d3eskf2N5n

Spectral Doppler through the right ventricular outflow tract

Fractional area change https://t.co/EerYxVytB0

myocardial performance index (Tei index) https://t.co/IEGrCMdkdk

Tissue Doppler imaging

Tricuspid annular plane systolic excursion (TAPSE)

And indirectly using the tricuspid regurgitation jet and IVC size/collapsibility.

The American society of Echocardiography has excellent guidelines on full assessment of RV function https://t.co/1llzJSBszL which are reviewed and simplified by Cardioserv here https://t.co/Mz49Il1Oq0

ARDS has its own set of challenges and RV function needs to be assessed in conjunction with LV function https://t.co/JUkxw8HNN4

Prof McLean’s advice: measurements are all well and good but can be misleading in practice…

His summary:

RV assessment is complex. Both subjective and objective parameters are necessary to quantify its function. Be careful with patients on inotropes as they confound things.

Prof McLean’s daily “go-tos” are TAPSE, TR/PASP. If still unsure, he adds FAC and TDI (S’).

Upcoming methods in future: speckle tracking/strain https://t.co/hNRuU6NDTg with reference values here https://t.co/GKq9dyeBYx

Prof reckons if you have a machine in your unit that currently measures strain, you should start using it as it will become mainstream in a few years time…

 

 

ICM year in review: respiratory, cardiodynamics and renal

This first session of the day in room Lisbon was a rapid run through of the journals’ most important papers of the last year  – a bumper year as the journals impact factor has soared.

Some notes below:

Respiratory papers

IC-GLOSSARI, the Intensive Care Global Study on Severe Acute Respiratory Infection which was a great ESICM project led by Yasser Sakr and is described as “a multicenter, multinational, 14-day inception cohort study”, in which I admit a COI in that i was involved on one of the sites, but a good paper in that it crossed continents and showed that admission to the ICU for severe lung infection is not only common but also associated with high morbidity and mortality rates.

http://link.springer.com/article/10.1007%2Fs00134-015-4206-2

ECMO epidemiology, this German study showed an increase in ECMO use especially amongst more elderly patients, since 2007.  VV ECMO seems to have reached a “plateau” in use. Mortality has decreased over time – the authors attribute this to experience – but is still stunningly high –  58 and 66 % for vv-ECMO and va-ECMO respectively.

http://link.springer.com/article/10.1007%2Fs00134-016-4273-z

ARDS rehabilitation – Pfoh and colleagues examined “physical declines occurring after hospital discharge” in people who survive ARDS and followed up patients for 5 years.  The headline is that most people decline, and older people and those with co-morbidities decline more.

http://link.springer.com/article/10.1007%2Fs00134-016-4530-1

Lung US training – This paper followed 11 respiratory therapists who had never used ultrasound before over 9 months and claims that 12 scans is the magic number to attain competence.  The jury is out…

http://link.springer.com/article/10.1007%2Fs00134-015-4102-9

The TRACHUS trial looked at ultrasound for tracheostomy – a good idea surely.  Anyway the paper says that it is safe and useful.  As @PhilMcglone said in his review for The Bottom Line – Why choose between bronchoscopy and ultrasound when we can use both?

http://link.springer.com/article/10.1007%2Fs00134-016-4218-6

Finally in the respiratory section this directions-type paper from Jeremy Beitler and the ARDSnet group (now ARDSne(x)t – see what they did there…) on personalising ARDS treatment. The research agenda is going to ask simultaneously both “whether a treatment affords clinically meaningful benefit and for whom.” Watch this space. Or read the paper:

http://link.springer.com/article/10.1007%2Fs00134-016-4331-6

Cardiodynamics and Ultrasound

Antoine Vieillard-Baron discussed the most important papers from this excitingly titled topic.

The FENICE trial was another landmark “global inception cohort study” and looked at fluid management and fluid boluses ( et al).  It showed massive variation in what a fluid bolus is and how it is used.  The question posed by AVL was why did only 2% of physicians use echo to manage fluid? Not enough trainers? Too difficult? Maurizio himself weighed in on the twitter chat below:

Then a study from 3 countries on point of care ultrasound use was presented.  Adrian has reviewed it nicely here for the NEXT journal club – or read the paper.  POCUS is underused generally, and only half the CVC insertions were performed under US guidance.

http://link.springer.com/article/10.1007%2Fs00134-015-3952-5

Finally a nice review article (authored by the presenter) on how to use ultrasound in ventilation management – 4 key areas:

  1. Assessment of cardiac function
  2. Assessment of diaphragmatic function
  3. Assessment of lung function
  4. Identification of pleural effusion

http://link.springer.com/article/10.1007%2Fs00134-016-4245-3

Kidneys

Matt wrote a nice blog on this yesterday, so briefly some of the papers discussed today were:

Statins in heart valve surgery

http://link.springer.com/article/10.1007%2Fs00134-016-4358-8

The kidney injury epidemiology study (AKI-EPI)

http://link.springer.com/article/10.1007%2Fs00134-015-3934-7

And the Truche study – looking again at continuous vs intermittent RRT:

http://link.springer.com/article/10.1007%2Fs00134-016-4404-6

About the Right Ventricle…

So the RV is a complex beast…

img_0405

  • A variety of ways to measure, but TAPSE still pretty good.
  • TAPSE evolves using TDI into the RV S’. It can predict right ventricular dysfunction (ejection fraction < 45%) with a sensitivity of 90% and a specificity of 85%. Reference here.
  • Get the end diastolic area in A4C and compare it to the LVEDA
    • <0.6 ratio is OK, >1.0 is severely enlarged.
  • Get a good idea of the RA pressure by actually measuring the nearby Hepatic Vein flow (subcostally). See here.
  • Essentially most RV assessment is qualitative right now.
  • But whatever you do, don’t forget to fully assess the left side of the heart to see if that’s the cause for the poor right side.

In summary, clinically fabulously important, and awaiting the gamut of measurements to define function that the LV has.

And anyone that knows me knows that I am going to add this to finish:

img_1320

Fluid Management Using Echocardiography

We know that you can use echocardiography to guide fluid management, but what should or could you use?

Antoine Vieillard-Baron

Static echo parameters

  • Predictors of fluid responsiveness
    • IVC collapse (beware of full hepatic vessels), but cannot be used in 20% Basic Echo
    • Left Ventricular Systolic Exclusion (the kissing ventricle) Basic Echo
    • Left Ventricular End Diastolic Area <5cm2/m2
    • Aortic VTI may show responsiveness, and mitral inflow tolerance

Philippe Vignon

Dynamic echo parameters

  • Passive leg raises (test it, take it back). Really good evidence
  • Aortic ΔVmax has the best sensitivity, but ΔSVC the best specificity (and alas a TOE measurement)

Just a few things to think about. But the best thing about this course has to be the level of detailed explanations coupled with great videos and lots of clinical cases. Which ESICM Postgraduate course will you be attending in Vienna?