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Implementation of Left Ventricular Ejection Fraction Assessment by Three-Dimensional Echocardiography in Daily Clinical Practice
Implementation of Left Ventricular Ejection Fraction Assessment by Three-Dimensional Echocardiography in Daily Clinical Practice
Bas M. van Dalen, MD, PhD Addy J.M. van Miltenburg, MD, PhD Department of Cardiology Franciscus Gasthuis Rotterdam, The Netherlands
To the Editor: Accurate assessment of left ventricular ejection fraction (LVEF) forms a routine part of daily echocardiographic practice. Currently, there is sufficient evidence to support the notion that assessment of LVEF by real-time three-dimensional echocardiography (RT3DE) should be considered the method of choice in routine practice.1 Nevertheless, implementation of RT3DE is still limited. There may be issues with, for example, work flow and training of sonographers.2 At our center, we have used a stepwise approach, aiming at the implementation of routine application of RT3DE for assessment of LVEF. First, space was generated in the daily work flow of the echocardiography laboratory. Specific echocardiographic protocols were developed on the basis of several documents developed by the American Society of Echocardiography and the European Association of Echocardiography,3-8 each one describing the required acquisitions for a specific indication. In the first 6 months after the introduction of these protocols, the mean number of images per echocardiographic study decreased significantly. The time needed for acquisition and analysis of a real-time three-dimensional echocardiographic data set for LVEF assessment takes (on average) <3 min. This time became available by decreasing the number of two-dimensional images. Second, local validation of LVEF by RT3DE was accomplished. Two sonographers were trained for LVEF assessment by RT3DE by the vendor of the ultrasound systems used in our clinic (2-day course). Following this, during a period of 1 month, they each acquired threedimensional volumetric data sets in 15 patients. After this initial training, both sonographers were required to acquire $10 fullvolume RT3DE data sets in patients scheduled for nuclear LVEF assessment. Measurement variability of LVEF assessment in the 25 patients in whom RT3DE and nuclear studies were available was 6.4 6 4.1% (mean difference for LVEF 3.9 6 2.3%; mean LVEF 64 6 9%), and the correlation between RT3DE and nuclear LVEF was highly significant (R = 0.90, P < .001). Third, LVEF assessment by RT3DE was implemented in daily practice by training the other five sonographers at our center and using the two RT3DE-experienced sonographers as the ‘‘gold standard.’’ Each novice RT3DE sonographer acquired 10 data sets that were also analyzed by one of the experienced RT3DE sonographers. Mean measurement variability was 4.9 6 2.4% (mean difference for LVEF 2.9 6 3.3%; mean LVEF 61 6 15%). Correlation analysis showed good agreement between the measurements performed by the more experienced and novice RT3DE sonographers (R = 0.94, P < .001). We believe that our stepwise approach, starting by generating space in the daily work flow, followed by local validation and finally application in daily clinical practice, may be successfully used to implement the routine use of RT3DE for LVEF assessment.
Hanneke J.M. Zuetenhorst, MD Department of Internal Medicine Franciscus Gasthuis Rotterdam, The Netherlands Constantin Dragoiescu, MD Department of Nuclear Medicine Franciscus Gasthuis Rotterdam, The Netherlands REFERENCES 1. Mor-Avi V, Sugeng L, Lang RM. Real-time 3-dimensional echocardiography: an integral component of the routine echocardiographic examination in adult patients? Circulation 2009;119:314-29. 2. Lang RM, Mor-Avi V, Dent JM, Kramer CM. Three-dimensional echocardiography: is it ready for everyday clinical use? JACC Cardiovasc Imaging 2009;2:114-7. 3. Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009;22:1-23. 4. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28:1-39. 5. Nagueh SF, Smiseth OA, Appleton CP, Byrd BF III, Dokainish H, Edvardsen T, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2016;29:277-314. 6. Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2017;30:372-92. 7. Evangelista A, Flachskampf F, Lancellotti P, Badano L, Aguilar R, Monaghan M, et al. European Association of Echocardiography recommendations for standardization of performance, digital storage and reporting of echocardiographic studies. Eur J Echocardiogr 2008;9: 438-48. 8. Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2017;30:303-71. http://dx.doi.org/10.1016/j.echo.2017.05.011
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Bas M. van Dalen, MD, PhD Addy J.M. van Miltenburg, MD, PhD Department of Cardiology Franciscus Gasthuis Rotterdam, The Netherlands
To the Editor: Accurate assessment of left ventricular ejection fraction (LVEF) forms a routine part of daily echocardiographic practice. Currently, there is sufficient evidence to support the notion that assessment of LVEF by real-time three-dimensional echocardiography (RT3DE) should be considered the method of choice in routine practice.1 Nevertheless, implementation of RT3DE is still limited. There may be issues with, for example, work flow and training of sonographers.2 At our center, we have used a stepwise approach, aiming at the implementation of routine application of RT3DE for assessment of LVEF. First, space was generated in the daily work flow of the echocardiography laboratory. Specific echocardiographic protocols were developed on the basis of several documents developed by the American Society of Echocardiography and the European Association of Echocardiography,3-8 each one describing the required acquisitions for a specific indication. In the first 6 months after the introduction of these protocols, the mean number of images per echocardiographic study decreased significantly. The time needed for acquisition and analysis of a real-time three-dimensional echocardiographic data set for LVEF assessment takes (on average) <3 min. This time became available by decreasing the number of two-dimensional images. Second, local validation of LVEF by RT3DE was accomplished. Two sonographers were trained for LVEF assessment by RT3DE by the vendor of the ultrasound systems used in our clinic (2-day course). Following this, during a period of 1 month, they each acquired threedimensional volumetric data sets in 15 patients. After this initial training, both sonographers were required to acquire $10 fullvolume RT3DE data sets in patients scheduled for nuclear LVEF assessment. Measurement variability of LVEF assessment in the 25 patients in whom RT3DE and nuclear studies were available was 6.4 6 4.1% (mean difference for LVEF 3.9 6 2.3%; mean LVEF 64 6 9%), and the correlation between RT3DE and nuclear LVEF was highly significant (R = 0.90, P < .001). Third, LVEF assessment by RT3DE was implemented in daily practice by training the other five sonographers at our center and using the two RT3DE-experienced sonographers as the ‘‘gold standard.’’ Each novice RT3DE sonographer acquired 10 data sets that were also analyzed by one of the experienced RT3DE sonographers. Mean measurement variability was 4.9 6 2.4% (mean difference for LVEF 2.9 6 3.3%; mean LVEF 61 6 15%). Correlation analysis showed good agreement between the measurements performed by the more experienced and novice RT3DE sonographers (R = 0.94, P < .001). We believe that our stepwise approach, starting by generating space in the daily work flow, followed by local validation and finally application in daily clinical practice, may be successfully used to implement the routine use of RT3DE for LVEF assessment.
Hanneke J.M. Zuetenhorst, MD Department of Internal Medicine Franciscus Gasthuis Rotterdam, The Netherlands Constantin Dragoiescu, MD Department of Nuclear Medicine Franciscus Gasthuis Rotterdam, The Netherlands REFERENCES 1. Mor-Avi V, Sugeng L, Lang RM. Real-time 3-dimensional echocardiography: an integral component of the routine echocardiographic examination in adult patients? Circulation 2009;119:314-29. 2. Lang RM, Mor-Avi V, Dent JM, Kramer CM. Three-dimensional echocardiography: is it ready for everyday clinical use? JACC Cardiovasc Imaging 2009;2:114-7. 3. Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009;22:1-23. 4. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28:1-39. 5. Nagueh SF, Smiseth OA, Appleton CP, Byrd BF III, Dokainish H, Edvardsen T, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2016;29:277-314. 6. Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2017;30:372-92. 7. Evangelista A, Flachskampf F, Lancellotti P, Badano L, Aguilar R, Monaghan M, et al. European Association of Echocardiography recommendations for standardization of performance, digital storage and reporting of echocardiographic studies. Eur J Echocardiogr 2008;9: 438-48. 8. Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2017;30:303-71. http://dx.doi.org/10.1016/j.echo.2017.05.011
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