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A new continuing quality improvement tool for evaluating transesophageal echocardiography
Heart,
Lung
and Circulation
2000; 9
A NEW CONTINUING QUALITY IMPROVEMENT TOOL EVALUATING TRANSESOPHAGEAL ECHOCARDIOGRAPHY G.M. Scalia*. K.O. Schwarz. D.Y. Leeer. M.J .Williams. Tischler. and W. J. Stewart. Cleveland Clinic Foundation, Cleveland, University of Rochester, NY. University of Vermont, VT.
48th Annual
FOR
Ohio.
Background: The proposal for Contmuing Quality Improvement (CQI) in echocardiography includes a component for the review of video tapes. The purpose of this study was to txial a new Quality Tool (QT) that we have developed and to test its accuracy and interobserver reproducibility and variability. Methods: The QT was applied to 58 TEE studies performed at an outside institution by three operators. Six reviewers from 3 institutions, blinded to operator name, reviewed and scored each study (total 3 13 reviews). A score, with precise definitions, from 1 (best) to 3 (worst) was given by each reviewer for a) presence and quality of images and b) adequacy and accuracy of reportmg, for each valve and chamber. A score for the overall study, and for its adequacy in amwring the “primary question” was also awarded. The mean score across all categories and by all reviewers was considered the standard for each study, against which all individual scores were compared. A mean value of <= 1.25 points was considered adequate quality for the QT, given the realities of clinical practice. Results: 29 of 58 studies achieved an adequate score by the standard (1581313 reviews). For each study, the interobserver concordance on adequate vs inadequate was 29413 13(93%). The mean score for all the studies was 1.45 points. The variability of any single grade from the group mean was 0.19 points (13%). Of the 155/313 reviewed as inadequate, 41 (24%) were considered adequate to address the primary indication. Conclusions: This reviewing and grading system has high interobserver concordance and low interobserver variability. It provides a validated CQI tool for the review and evaluation of echocardiograpiuc tapes
Scientific
IS SYSTOLIC MYOCARDUL DOPPLER TO STRESS INFLUENCED BY LOADING * <. Queensland, Brisbane, Australia.
Meeting
of CSANZ
A143
VELOCITY RESPONSE CONDITIONS? University of
Systolic myocardial Doppler velocity (MDV) is reduced by ischemia and may be useful for quantitation of regional myocardial function. However, hemodyoamic responses to stress might be significant contributors to MDV independent of Ischerma. We sought to define the load-dependence of systohc MDV at rest and stress. Methods: We examined 50 normal patients undergoing dobutamine stress echo (36 male, mean age 48). Systohc (SBP and diastolic blood pressure (DBP) and heart rate (HR) were recorded at each stage. Images were acquired as digital cineloops (Vingmed system Five) in 3 standard apical views at each stage. Independent experienced readers of stress echo assessed wall motion as normal. Lefi ventricular volumes were assessed at end-systole (LVESV) and end-diastole (LVEDV) at rest and peak stress as an offline analysis. MDV was assessed in all basal and mid segments at rest and peak stress (Echopac ~6.2). Influence of hemodynamic and volume variables on MDV were made by comparing MDV in lower and upper quartiles of these variables as well as by Pearson correlation. Results: No slgniticant correlation was found between peak MDV and heart rate, systolic or diastolic blood pressure, diastolic or systolic iefi ventricular volumes or left ventricular mass; I I IRest IStress Background:
Regional myocardial velocities are not significantly influenced by blood pressure, pulse rate or left ventricular volume. These findings suggest that quantitation of regional myocardial velocities may be apphcable to a wide spectrum of ventricular states and stress responses.
Conclusions:
A NEW QUANTITATIVE METHOD FOR EVALUATION OF SYSTOLIC AND DIASTOLIC MYOCARDIAL FUNCTION USING HIGH FRAME RATE DIGITAL ECHOCARDIOGRAPHY AND VARIABLE REFERENCE M-MODE. ” . e University of Queensland and The Prince Charles Hospital, Brisbane, Qld. Background: New pixel reconstructive software can synthesise angle and translation corrected left ventricular M-Mode sections from which direct temporal and spatial measurements oan provide parameters of systolic and diastolic myocardial function. Method: High frame rate (12Oil4fps) 2D parasternal long axis cycles were acquired from eighty one normal subjects and a Variable Reference (VR) M-Mode was synthesised providing a basal anterior septal @AS) and basal posterior (BP) myocardial segmental section. From the onset of the QRS complex the timing of segmental end systole (sys), end early diastole (ed) and end diastole (d) was measured from the endooardial surface. Myocardial thickness (T) at each time was also measured and fractional wall thickening (FM), duration (D), and mean rates of thickening and thinning were derived for sys, ed and d. Segmental activation delay (SAD) was defined as the time between electrical ventricular activation and the onset of mechanical segmental systole. Reproducibility was tested by comparison of independent blinded observations. Reeulta: Temporal parameters (ms) Segment SAD Ded Dd osve BAS(n=sl) 44~9 26O%XJ 83*35 570*170 BP(n=al) 8421 28Ot32 11OtiB 55oi170 Spati;;;rameters (ems) Tdias Ted FWT% Sw EAS(n=W) 0.79ti.14 1.2OM.14 0.840.16 50.56*13.47 EP(n=sl) 0.78M.13 1.3&0.19 0.82%~.13 67.86t16.27 Derived parameters - Raa of thickenin! and Thinning (cm/s) Se9 sys BAS(n=sl) 1.58&47 5.18ti.89 0.75iO.28 BP(n=s1) 1.9oi0.45 4.69ti.20 1.02iO.33 Reproducibility was good (1~~0.824, p~O.0005) with superior correlation of temporal measurements. Conclueiona: Spatial and temporal mapping of VR M-Modes derived from high frame rate digital echocardiograms is feasible and may provide new insights into myocardial systolic and diastolic physiology. This study defines normal adult values for these new quantitative parameters and will allow application of this technique to various myocardial pathologies.
TISSUE DOPPLER MEASUREMENT OF VELOCITY OF MITRAL ANNULAR ASCENT IN LATE DIASTOLE RELIABLY ESTIMATES ATRIAL FUNCTION. L Thomas*‘. DYC Leune2. N B Schiller’ and D L. Ross’. ‘UCSF, San Francisco, USA,*Liverpool Hospital, Sydney and ’ Westmead Hospital, Sydney, Australia. Atrial function is clinically relevant as it contributes upto a third of cardiac output, especially in diseased states of the ventricle. We hypothesized that the velocity of mitral annulus ascent secondary to atrial contraction (A’) measured using Doppler tissue imaging (DTI) would provide a novel echocardiographic parameter of atrial function. We studied 45 patients in sinus rhythm without significant valvular abnormalities with 2D echocardiography. 30 had normal left ventricular (LV) fimction (Groupl) and 15 had LV hypertrophy*LV dysfunction (Group 2). A’ was measured by DTI in the apical 4 chamber view as the peak velocity of mitral annular ascent with atrial contraction in late diastole. Mitral inflow A wave velocity, A wave velocity time integral (VTI) and atrial k-action ([A wave VTI/ Total mitral inflow VTI] X lOO%), which are commonly used echocardiographic parameters of atrial function were also measured in all patients. Results: A’ velocity was significantly higher in Group 1 than in Group 2 (9.510.5 vs 7.7hO.6 cm/set, p=O.O3. In Group 1, A’ velocity did not correlate with mitral inflow A wave velocity or atria1 fraction. In Group 2, A’ velocity significantly correlated with mitral inflow A wave velocity (~0.75, p=O.OOl) and atrial fraction (~0.6, p=O.O2). Conclusion: The velocity of ascent of mitral annulus with atria1 contraction was significantly decreased in LV hypertrophy and LV dysfunction which may cause a decrease in ventricular compliance resulting in atrial dysfunction. In this group, the A’ was noted to correlate with other markers of atrial function. The reliability and sensitivity of this parameter requires assessment in a range of disease states to further elucidate its utilitv.
Lung
and Circulation
2000; 9
A NEW CONTINUING QUALITY IMPROVEMENT TOOL EVALUATING TRANSESOPHAGEAL ECHOCARDIOGRAPHY G.M. Scalia*. K.O. Schwarz. D.Y. Leeer. M.J .Williams. Tischler. and W. J. Stewart. Cleveland Clinic Foundation, Cleveland, University of Rochester, NY. University of Vermont, VT.
48th Annual
FOR
Ohio.
Background: The proposal for Contmuing Quality Improvement (CQI) in echocardiography includes a component for the review of video tapes. The purpose of this study was to txial a new Quality Tool (QT) that we have developed and to test its accuracy and interobserver reproducibility and variability. Methods: The QT was applied to 58 TEE studies performed at an outside institution by three operators. Six reviewers from 3 institutions, blinded to operator name, reviewed and scored each study (total 3 13 reviews). A score, with precise definitions, from 1 (best) to 3 (worst) was given by each reviewer for a) presence and quality of images and b) adequacy and accuracy of reportmg, for each valve and chamber. A score for the overall study, and for its adequacy in amwring the “primary question” was also awarded. The mean score across all categories and by all reviewers was considered the standard for each study, against which all individual scores were compared. A mean value of <= 1.25 points was considered adequate quality for the QT, given the realities of clinical practice. Results: 29 of 58 studies achieved an adequate score by the standard (1581313 reviews). For each study, the interobserver concordance on adequate vs inadequate was 29413 13(93%). The mean score for all the studies was 1.45 points. The variability of any single grade from the group mean was 0.19 points (13%). Of the 155/313 reviewed as inadequate, 41 (24%) were considered adequate to address the primary indication. Conclusions: This reviewing and grading system has high interobserver concordance and low interobserver variability. It provides a validated CQI tool for the review and evaluation of echocardiograpiuc tapes
Scientific
IS SYSTOLIC MYOCARDUL DOPPLER TO STRESS INFLUENCED BY LOADING * <. Queensland, Brisbane, Australia.
Meeting
of CSANZ
A143
VELOCITY RESPONSE CONDITIONS? University of
Systolic myocardial Doppler velocity (MDV) is reduced by ischemia and may be useful for quantitation of regional myocardial function. However, hemodyoamic responses to stress might be significant contributors to MDV independent of Ischerma. We sought to define the load-dependence of systohc MDV at rest and stress. Methods: We examined 50 normal patients undergoing dobutamine stress echo (36 male, mean age 48). Systohc (SBP and diastolic blood pressure (DBP) and heart rate (HR) were recorded at each stage. Images were acquired as digital cineloops (Vingmed system Five) in 3 standard apical views at each stage. Independent experienced readers of stress echo assessed wall motion as normal. Lefi ventricular volumes were assessed at end-systole (LVESV) and end-diastole (LVEDV) at rest and peak stress as an offline analysis. MDV was assessed in all basal and mid segments at rest and peak stress (Echopac ~6.2). Influence of hemodynamic and volume variables on MDV were made by comparing MDV in lower and upper quartiles of these variables as well as by Pearson correlation. Results: No slgniticant correlation was found between peak MDV and heart rate, systolic or diastolic blood pressure, diastolic or systolic iefi ventricular volumes or left ventricular mass; I I IRest IStress Background:
Regional myocardial velocities are not significantly influenced by blood pressure, pulse rate or left ventricular volume. These findings suggest that quantitation of regional myocardial velocities may be apphcable to a wide spectrum of ventricular states and stress responses.
Conclusions:
A NEW QUANTITATIVE METHOD FOR EVALUATION OF SYSTOLIC AND DIASTOLIC MYOCARDIAL FUNCTION USING HIGH FRAME RATE DIGITAL ECHOCARDIOGRAPHY AND VARIABLE REFERENCE M-MODE. ” . e University of Queensland and The Prince Charles Hospital, Brisbane, Qld. Background: New pixel reconstructive software can synthesise angle and translation corrected left ventricular M-Mode sections from which direct temporal and spatial measurements oan provide parameters of systolic and diastolic myocardial function. Method: High frame rate (12Oil4fps) 2D parasternal long axis cycles were acquired from eighty one normal subjects and a Variable Reference (VR) M-Mode was synthesised providing a basal anterior septal @AS) and basal posterior (BP) myocardial segmental section. From the onset of the QRS complex the timing of segmental end systole (sys), end early diastole (ed) and end diastole (d) was measured from the endooardial surface. Myocardial thickness (T) at each time was also measured and fractional wall thickening (FM), duration (D), and mean rates of thickening and thinning were derived for sys, ed and d. Segmental activation delay (SAD) was defined as the time between electrical ventricular activation and the onset of mechanical segmental systole. Reproducibility was tested by comparison of independent blinded observations. Reeulta: Temporal parameters (ms) Segment SAD Ded Dd osve BAS(n=sl) 44~9 26O%XJ 83*35 570*170 BP(n=al) 8421 28Ot32 11OtiB 55oi170 Spati;;;rameters (ems) Tdias Ted FWT% Sw EAS(n=W) 0.79ti.14 1.2OM.14 0.840.16 50.56*13.47 EP(n=sl) 0.78M.13 1.3&0.19 0.82%~.13 67.86t16.27 Derived parameters - Raa of thickenin! and Thinning (cm/s) Se9 sys BAS(n=sl) 1.58&47 5.18ti.89 0.75iO.28 BP(n=s1) 1.9oi0.45 4.69ti.20 1.02iO.33 Reproducibility was good (1~~0.824, p~O.0005) with superior correlation of temporal measurements. Conclueiona: Spatial and temporal mapping of VR M-Modes derived from high frame rate digital echocardiograms is feasible and may provide new insights into myocardial systolic and diastolic physiology. This study defines normal adult values for these new quantitative parameters and will allow application of this technique to various myocardial pathologies.
TISSUE DOPPLER MEASUREMENT OF VELOCITY OF MITRAL ANNULAR ASCENT IN LATE DIASTOLE RELIABLY ESTIMATES ATRIAL FUNCTION. L Thomas*‘. DYC Leune2. N B Schiller’ and D L. Ross’. ‘UCSF, San Francisco, USA,*Liverpool Hospital, Sydney and ’ Westmead Hospital, Sydney, Australia. Atrial function is clinically relevant as it contributes upto a third of cardiac output, especially in diseased states of the ventricle. We hypothesized that the velocity of mitral annulus ascent secondary to atrial contraction (A’) measured using Doppler tissue imaging (DTI) would provide a novel echocardiographic parameter of atrial function. We studied 45 patients in sinus rhythm without significant valvular abnormalities with 2D echocardiography. 30 had normal left ventricular (LV) fimction (Groupl) and 15 had LV hypertrophy*LV dysfunction (Group 2). A’ was measured by DTI in the apical 4 chamber view as the peak velocity of mitral annular ascent with atrial contraction in late diastole. Mitral inflow A wave velocity, A wave velocity time integral (VTI) and atrial k-action ([A wave VTI/ Total mitral inflow VTI] X lOO%), which are commonly used echocardiographic parameters of atrial function were also measured in all patients. Results: A’ velocity was significantly higher in Group 1 than in Group 2 (9.510.5 vs 7.7hO.6 cm/set, p=O.O3. In Group 1, A’ velocity did not correlate with mitral inflow A wave velocity or atria1 fraction. In Group 2, A’ velocity significantly correlated with mitral inflow A wave velocity (~0.75, p=O.OOl) and atrial fraction (~0.6, p=O.O2). Conclusion: The velocity of ascent of mitral annulus with atria1 contraction was significantly decreased in LV hypertrophy and LV dysfunction which may cause a decrease in ventricular compliance resulting in atrial dysfunction. In this group, the A’ was noted to correlate with other markers of atrial function. The reliability and sensitivity of this parameter requires assessment in a range of disease states to further elucidate its utilitv.