Contrast-enhanced quantitation of left ventricular ejection fraction: What is the best method?

The need to enhance the echocardiographic determination of left ventricular ejection fraction (LVEF) is greatest in patients with suboptimal images. We have previously demonstrated that in difficult-to-image patients, contrast-enhanced power harmonic imaging resulted in accurate calculation of LVEF by using Simpson's method. However, the incremental accuracy of contrast enhancement with other methods of determining LVEF has not been examined. This study prospectively assessed the comparative accuracy of LVEF determination by using the Quinones' method with fundamental imaging (FU), tissue harmonic imaging (TH), contrast-enhanced harmonic imaging [TH(CON)], as well as Quinones' method with contrast-enhanced power harmonic imaging [POW(QUIN)] in 62 patients with suboptimal images. LVEF was also calculated by using contrast-enhanced power harmonic imaging and Simpson's method [POW(SIMP)] in these patients. We demonstrated that LVEF calculated from the POW(QUIN) mode had the best agreement with radionuclide angiography (standard of comparison) compared with FU, TH, and TH(CON). However, POW(SIMP) was even more accurate. In conclusion, when the Quinones' method was used to calculate LVEF in difficult-to-image patients, POW(QUIN) mode was the most accurate. However, POW(SIMP) was even more accurate and should be the method of choice when a high degree of quantitative accuracy is required.     

Echocardiographic Parameters that Predict Outcome in Aortic Atresia Patients Undergoing Comprehensive Stage II Procedure

Background. The hybrid procedure is one option for palliating patients with hypoplastic left heart syndrome. As experience increases with this palliation, the physiology and its influence on outcome can be better assessed. The goal of this study was to determine if echocardiographic parameters correlate with post-operative variables in patients with aortic atresia undergoing the comprehensive Stage II procedure. Methods. Retrospective chart review on all patients with aortic atresia, who underwent the comprehensive Stage II procedure from January 2002 to December 2008, was performed. Echocardiographic indices were evaluated and correlations were made with peri-operative and hospital variables. Pair-wise Pearson's correlation tests were used to analyze the associations between continuous measures. Results. Thirty-four patients met inclusion criteria. Age at comprehensive Stage II procedure was 0.45 ± 0.13 years and body surface area was 0.31 ± 0.04 m². Right ventricle (RV) percentage change was 45 ± 10%, eccentricity index was 1.96 ± 0.45, estimated systemic cardiac output was 7.68 ± 2.56 L/min/m² and estimated effective systemic cardiac output was 5.15 ± 2.24 L/min/m². Retrograde patent ductus arteriosu (PDA) velocity time integral (VTI) correlated with log pre-bypass lactate and maximum lactate (r = 0.53, 0.44). PDA regurgitant fraction correlated with log post-bypass lactate, length of intubation, and urine output on day four (r = 0.39, 0.46, −0.37). RV percentage change correlated with log pre-bypass lactate, and urine output on days four and five (r =−0.38, 0.43, 0.54). No echocardiographic parameter predicted renal or liver insufficiency, dialysis, extracorporeal membrane oxygenation use, or hospital death. Conclusion. Retrograde PDA VTI and RV percent change correlated with some peri-operative variables though no echocardiographic parameter was associated with any major morbidities or mortality. Newer echocardiographic techniques may better predict comprehensive stage II outcomes.     

Prenatal Diagnosis of Cardiovascular Disease

Technological advances in ultrasound have led to a greater ability to monitor the internal life of the fetus. This has led to fascinating discoveries of fetal physiology as well as to the natural progression of some cardiac defects while in utero. Watching this progression has stimulated the medical/research community to find ways to intervene in those cardiac defects with the highest morbidity and mortality. Although still in the early stages, the challenge continues to be explored in an attempt to stop progression to a more significant defect in utero. This article explores the diagnosis, evaluation for intervention, and the role of a multidisciplinary group in educating, preparing, and caring for these families before birth.     

Proceedings: Beyond Ultrasound First Forum on Improving the Quality of Ultrasound Imaging in Obstetrics and Gynecology

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.     

Two Cases of Heterotopic Pregnancy

We present 2 recent cases of heterotopic pregnancy in which bedside sonography performed by the treating emergency physician was used to identify the heterotopic pregnancy and facilitate prompt gynecologic intervention. The cases, the sonographic approach to the diagnosis of heterotopic pregnancy, and a review of the literature are presented.     

The Ultrasound‐Only Central Venous Catheter Placement and Confirmation Procedure

The placement of a central venous catheter remains an important intervention in the care of critically ill patients in the emergency department. We propose an ultrasound‐first protocol for 3 aspects of central venous catheter placement above the diaphragm: dynamic procedural guidance, evaluation for pneumothorax, and confirmation of the catheter tip location.