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1.  Systematic training in focused cardiopulmonary ultrasound affects decision-making in the prehospital setting – two case reports 
We present two cases from the Helicopter Emergency Medical Services (HEMS) in Denmark, in which prehospital physicians trained in cardiac ultrasound (FATE) disclosed significant pathology that induced a radical change for the critical patient’s course.
PMCID: PMC4016794  PMID: 24886932
Focused ultrasound; Prehospital; Echocardiography; Pulmonary embolism; Pericardial effusion; Aortic dissection; Dyspnea
2.  Assessment of cardiac pathology by point-of-care ultrasonography performed by a novice examiner is comparable to the gold standard 
The aim of the study was to compare the diagnostic accuracy of point-of-care cardiac ultrasonography performed by a novice examiner against results from a specialist in cardiology with expert skills in echocardiography, with regard to the assessment of six clinically relevant cardiac conditions in a population of ward patients from the Department of Cardiology or the Department of Cardiothoracic Surgery.
Cardiac ultrasonography was performed by a novice examiner at the bedside and images were interpreted in a point-of-care context with dichotomous outcomes (yes/no). Six outcome categories were defined: 1) pericardial effusion (≥10 mm), 2) left ventricular dilatation (≥62 mm), 3) right ventricular dilatation (≥42 mm or ≥ left ventricular diameter), 4) left ventricular hypertrophy (≥13 mm), 5) left ventricular failure (EF ≤ 40%), 6) aortic stenosis (maximum flow velocity ≥3 m/s). The examiner was blinded to the patients’ medical history and results from previous echocardiographic examinations. Results from the interpreted point-of-care ultrasonography examination were compared with echocardiographic diagnosis made by a specialist in cardiology.
A total of 102 medical and surgical patients were included. Assessments were made in six categories totalling 612 assessments. There was agreement between the novice examiner and the specialist in 95.6% of the cases; overall sensitivity was 0.91 and specificity was 0.97. Positive predictive value was 0.92 and negative predictive value was 0.97. Kappa statistics showed good agreement between observers (κ=0.88).
This study showed that a novice examiner was able to detect common and significant heart pathology in six different categories with good accuracy using POC ultrasonography.
PMCID: PMC3866928  PMID: 24330752
Point-of-care; Ultrasonography; Echocardiography; Bedside; Heart disease
4.  Systolic heart function remains depressed for at least 30 days after on-pump cardiac surgery 
The myocardial recovery time following on-pump cardiac surgery remains uncertain. Global peak longitudinal strain is a sensitive measure of endocardial function which is most susceptible to ischaemia. We aimed to evaluate changes in global peak longitudinal strain up to 6 months after surgery and to compare initial changes with alterations in troponin T. Secondarily, we aimed to describe perioperative changes in strain of the inter-ventricular septum when compared with reference segments.
Patients scheduled for coronary bypass, aortic valve replacement or combination procedures were enrolled. Echocardiography was performed on the day before surgery, the day after surgery, 4 days after surgery, 30 days after surgery and 6 months after surgery. Troponin T was measured 3, 16 and 24 h following procedure.
Forty patients were enrolled and one was later excluded. Global peak longitudinal strain decreased from −14.5 ± 3.33% preoperatively to −9.98 ± 3.09% and −10.57 ± 3.16% on the first and fourth postoperative day, respectively. Global strain was still reduced on the 30th postoperative day, but had returned to preoperative values 6 months after surgery. Absolute values and relative changes in global strain did not correlate with postoperative peak troponin T measurements. Strain of the inter-ventricular septum was unaffected by surgery as opposed to reference segments, although septal displacement in the longitudinal direction decreased from 12.0 ± 3.75 mm preoperatively to 3.58 ± 4.22 mm 4 days after surgery.
Global peak longitudinal strain was reduced for at least 30 days after on-pump cardiac surgery and seems to represent a more sensitive marker of myocardial function than ejection fraction. The decrease in global strain was not reflected in troponin T measurements. The visual, echocardiographic impression of septal dysfunction may be a translational phenomenon, as septal strain was unaffected by surgery.
PMCID: PMC3422956  PMID: 22685027
Thoracic surgery; Echocardiography; Ischaemia reperfusion injury; Ventricular septum; Troponin T
5.  Acute effects of sildenafil and dobutamine in the hypertrophic and failing right heart in vivo 
Pulmonary Circulation  2013;3(3):599-610.
The purpose of this study was to investigate whether acute intravenous administration of the phosphodiesterase type 5 (PDE-5) inhibitor sildenafil in a single clinically relevant dose improves the in vivo function of the hypertrophic and failing right ventricle (RV). Wistar rats () were subjected to pulmonary trunk banding (PTB) causing RV hypertrophy and failure. Four weeks after surgery, they were randomized to receive an intravenous bolus dose of sildenafil (1 mg/kg; ), vehicle (), or dobutamine (10 μg/kg; ). Invasive RV pressures were recorded continuously, and transthoracic echocardiography was performed 1, 5, 15, 25, 35, 50, 70, and 90 minutes after injecting the bolus. Cardiac function was compared to baseline measurements to evaluate the in vivo effects of each specific treatment. The PTB procedure caused significant hypertrophy, cardiac fibrosis, and reduction in RV function evaluated by echocardiography (TAPSE) and invasive pressure measurements. Sildenafil did not improve the function of the hypertrophic failing right heart in vivo, measured by TAPSE, RV systolic pressure (RVsP), and dp/dtmax. Dobutamine improved RV function 1 minute after injection measured by TAPSE ( vs. cm; ), RVsP ( vs. mmHg; ), and dp/dtmax ( vs. mmHg/s; ). Acute administration of the PDE-5 inhibitor sildenafil in a single clinically relevant dose did not modulate the in vivo function of the hypertrophic failing right heart of the rat measured by echocardiography and invasive hemodynamics. In the same model, dobutamine acutely improved RV function.
PMCID: PMC4070794  PMID: 24618544
right heart failure; pulmonary circulation and disease; sildenafil; cardiovascular pharmacology; animal models of human disease
6.  The intrapleural volume threshold for ultrasound detection of pneumothoraces: An experimental study on porcine models 
Small pneumothoraxes (PTXs) may not impart an immediate threat to trauma patients after chest injuries. However, the amount of pleural air may increase and become a concern for patients who require positive pressure ventilation or air ambulance transport. Lung ultrasonography (US) is a reliable tool in finding intrapleural air, but the performance characteristics regarding the detection of small PTXs need to be defined. The study aimed to define the volume threshold of intrapleural air when PTXs are accurately diagnosed with US and compare this volume with that for chest x-ray (CXR).
Air was insufflated into a unilateral pleural catheter in seven incremental steps (10, 25, 50, 100, 200, 350 and 500 mL) in 20 intubated porcine models, followed by a diagnostic evaluation with US and a supine anteroposterior CXR. The sonographers continued the US scanning until the PTXs could be ruled in, based on the pathognomonic US “lung point” sign. The corresponding threshold volume was noted. A senior radiologist interpreted the CXR images.
The mean threshold volume to confirm the diagnosis of PTX using US was 18 mL (standard deviation of 13 mL). Sixty-five percent of the PTXs were already diagnosed at 10 mL of intrapleural air; 25%, at 25 mL; and the last 10%, at 50 mL. At an air volume of 50 mL, the radiologist only identified four out of 20 PTXs in the CXR pictures; i.e., a sensitivity of 20% (95% CI: 7%, 44%). The sensitivity of CXR increased as a function of volume but leveled off at 67%, leaving one-third (1/3) of the PTXs unidentified after 500 mL of insufflated air.
Lung US is very accurate in diagnosing even small amounts of intrapleural air and should be performed by clinicians treating chest trauma patients when PTX is among the differential diagnoses.
PMCID: PMC3602194  PMID: 23453044
(MeSH terms): Pneumothorax; Ultrasonography; Chest x-ray; Computed tomography; Pleura and (models animal)
7.  Echocardiographic Measures of Diastolic Function Are Preload Dependent during Triggered Positive Pressure Ventilation: A Controlled Crossover Study in Healthy Subjects 
Background. The use of echocardiography in intensive care settings impacts decision making. A prerequisite for the use of echocardiography is relative resistance to changes in volume status and levels of positive pressure ventilation (PPV). Studies on indices of diastolic function report conflicting results with regard to dependence on volume status. Evidence is scarce on PPV. Methods. Ten healthy subjects were exposed to 6 levels of positive end-expiratory pressure (PEEP) and pressure support (PS) following a baseline reading. All ventilator settings were performed at three positions: horizontal, reverse-Trendelenburg, and Trendelenburg. Echocardiography was performed throughout. Results. During spontaneous breathing, early diastolic transmitral velocity (E) changed with positioning (P < 0.001), whereas early diastolic velocity of the mitral annulus (e′) was independent (P = 0.263). With PPV, E and e′ proved preload dependent (P   values < 0.001). Increases in PEEP, PS, or a combination influenced E and e′ in reverse-Trendelenburg- and horizontal positions, but not in the Trendelenburg position. Discussion. The change towards preload dependency of e′ with PPV suggests that PPV increases myocardial preload sensitivity. The susceptibility of E and e′ to preload changes during PPV discourages their use in settings of volume shifts or during changes in ventilator settings. Conclusion. Positioning and PPV affect E and e′.
PMCID: PMC3463162  PMID: 23050132
8.  Limited intervention improves technical skill in focus assessed transthoracic echocardiography among novice examiners 
BMC Medical Education  2012;12:65.
Previous studies addressing teaching and learning in point-of-care ultrasound have primarily focussed on image interpretation and not on the technical quality of the images. We hypothesized that a limited intervention of 10 supervised examinations would improve the technical skills in Focus Assessed Transthoracic Echocardiography (FATE) and that physicians with no experience in FATE would quickly adopt technical skills allowing for image quality suitable for interpretation.
Twenty-one physicians with no previous training in FATE or echocardiography (Novices) participated in the study and a reference group of three examiners with more than 10 years of experience in echocardiography (Experts) was included. Novices received an initial theoretical and practical introduction (2 hours), after which baseline examinations were performed on two healthy volunteers. Subsequently all physicians were scheduled to a separate intervention day comprising ten supervised FATE examinations. For effect measurement a second examination (evaluation) of the same two healthy volunteers from the baseline examination was performed.
At baseline 86% of images obtained by novices were suitable for interpretation, on evaluation this was 93% (p = 0.005). 100% of images obtained by experts were suitable for interpretation. Mean global image rating on baseline examinations was 70.2 (CI 68.0-72.4) and mean global image rating after intervention was 75.0 (CI 72.9-77.0), p = 0.0002. In comparison, mean global image rating in the expert group was 89.8 (CI 88.8-90.9).
Improvement of technical skills in FATE can be achieved with a limited intervention and upon completion of intervention 93% of images achieved are suitable for clinical interpretation.
PMCID: PMC3477018  PMID: 22863138
Point-of-care; Bedside; Ultrasound; Echocardiography; Learning
9.  Focused sonographic examination of the heart, lungs and deep veins in an unselected population of acute admitted patients with respiratory symptoms: a protocol for a prospective, blinded, randomised controlled trial 
BMJ Open  2012;2(3):e001369.
Patients admitted to hospital with acute respiratory symptoms remain a diagnostic challenge for the emergency physician. The use of focused sonography may improve the initial diagnostics, as most of the diseases, commonly seen and misdiagnosed in patients with acute respiratory symptoms, can be diagnosed with sonography. The protocol describes a prospective, blinded, randomised controlled trial that aims to assess the diagnostic impact of a pragmatic implementation of focused sonography of the heart, lungs and deep veins as a diagnostic modality in acute admitted patients with respiratory symptoms.
Methods and analysis
The primary outcome of the study is the number of patients with a correct presumptive diagnosis within 4 h of admission to the emergency department. The patient is randomised to either an intervention or a control group. In the intervention group, the usual initial diagnostic work up is supplemented by focused sonographic examination of the heart, lungs and deep veins of the legs. In the control group, usual diagnostic work up is performed. The χ2 test, alternatively the Fischer exact test will be used, to establish whether there is a difference in the distribution of the total number of patients with a correct/incorrect ‘4 h’ presumptive diagnosis in the control group and in the intervention group.
Ethics and dissemination
This clinical trial is performed according to the Declaration of Helsinki and has been approved by the Regional Scientific Ethical Committee for Southern Denmark and the Danish Data Protection Agency. The results of the trial will be published according to the CONSORT statement with the extension for pragmatic trials. The results of the trial will be published in a peer-reviewed scientific journal regardless of the outcome.
Trial registration number
This study is registered at, registration number NCT01486394.
Article summary
Article focus
Focused sonography of the heart, lungs and deep veins.
Initial diagnostics of acute admitted patients with respiratory symptoms.
Key messages
The results of the study may help to determine whether sonography should be included as a fully integrated part of the primary evaluation in these patients.
Strengths and limitations of this study
First randomised trial to compare the overall diagnostic performance between the conventional approach and an approach including focused sonography to evaluate and diagnose acute admitted patients with respiratory symptoms, admitted to an emergency department.
Pragmatic design with inclusion of most patients with respiratory symptoms.
Single-centre study that could affect external validity.
Study not powered to investigate morbidity or mortality.
PMCID: PMC3367153  PMID: 22649177
10.  Left Ventricular Longitudinal Function Assessed by Speckle Tracking Ultrasound from a Single Apical Imaging Plane 
Background. Transthoracic ultrasonography of the heart is valuable in monitoring and treatment of critically ill patients. Speckle tracking ultrasound (STU) has proven valid in estimating left ventricular systolic deformation. The aims of the study were to compare conventional and automated STU and to determine whether left ventricular systolic deformation could be estimated from one single imaging plane. Methods. 2D-echocardiography cine-loops were obtained from 20 patients for off-line speckle tracking analysis, consisting of manually tracing of the endocardial border (conventional method) or automatically drawn boundaries (automated method). Results. We found a bias of 0,6 (95% CI −2.2−3.3) for global peak systolic strain comparing the automated and the conventional method. Comparing global peak systolic strain of apical 4-chamber cine-loops with averaged Global Peak Strain obtained from apical 4, 2 and long axis cine-loops, showed a bias of 0.1 (95% CI −3.9−4.0). The agreement between subcostal 4-chamber and apical 4-chamber global peak systolic strain was 4.4 (95% CI −3.7−12.5). Conclusion. We found good agreement between the conventional and the automated method. STU applied to single apical 4-chamber cine-loops is in excellent agreement with overall averaged global peak systolic strain, while subcostal 4-chamber cine-loops proved less compliant with speckle tracking ultrasound.
PMCID: PMC3348630  PMID: 22611488
12.  Subcoronary versus supracoronary aortic stenosis. an experimental evaluation 
Valvular aortic stenosis is the most common cause of left ventricular hypertrophy due to gradually increasing pressure work. As the stenosis develop the left ventricular hypertrophy may lead to congestive heart failure, increased risk of perioperative complications and also increased risk of sudden death. A functional porcine model imitating the pathophysiological nature of valvular aortic stenosis is very much sought after in order to study the geometrical and pathophysiological changes of the left ventricle, timing of surgery and also pharmacological therapy in this patient group.
Earlier we developed a porcine model for aortic stenosis based on supracoronary aortic banding, this model may not completely imitate the pathophysiological changes that occurs when valvular aortic stenosis is present including the coronary blood flow. It would therefore be desirable to optimize this model according to the localization of the stenosis.
In 20 kg pigs subcoronary (n = 8), supracoronary aortic banding (n = 8) or sham operation (n = 4) was preformed via a left lateral thoracotomy. The primary endpoint was left ventricular wall thickness; secondary endpoints were heart/body weight ratio and the systolic/diastolic blood flow ratio in the left anterior descending coronary. Statistical evaluation by oneway anova and unpaired t-test.
Sub- and supracoronary banding induce an equal degree of left ventricular hypertrophy compared with the control group. The coronary blood flow ratio was slightly but not significantly higher in the supracoronary group (ratio = 0.45) compared with the two other groups (subcoronary ratio = 0.36, control ratio = 0.34).
A human pathophysiologically compatible porcine model for valvular aortic stenosis was developed by performing subcoronary aortic banding. Sub- and supracoronary aortic banding induce an equal degree of left ventricular hypertrophy. This model may be valid for experimental investigations of aortic valve stenosis but studies of left ventricular hypertrophy can be studied equally well by graduated constriction of the ascending aorta.
PMCID: PMC3173302  PMID: 21859468
subcoronary; supracoronary; porcine; aortic stenosis; myocardial hypertrophy
13.  An automated in vitro model for the evaluation of ultrasound modalities measuring myocardial deformation 
Echocardiography is the method of choice when one wishes to examine myocardial function. Qualitative assessment of the 2D grey scale images obtained is subjective, and objective methods are required. Speckle Tracking Ultrasound is an emerging technology, offering an objective mean of quantifying left ventricular wall motion. However, before a new ultrasound technology can be adopted in the clinic, accuracy and reproducibility needs to be investigated.
It was hypothesized that the collection of ultrasound sample data from an in vitro model could be automated. The aim was to optimize an in vitro model to allow for efficient collection of sample data.
Material & Methods
A tissue-mimicking phantom was made from water, gelatin powder, psyllium fibers and a preservative. Sonomicrometry crystals were molded into the phantom. The solid phantom was mounted in a stable stand and cyclically compressed. Peak strain was then measured by Speckle Tracking Ultrasound and sonomicrometry.
We succeeded in automating the acquisition and analysis of sample data. Sample data was collected at a rate of 200 measurement pairs in 30 minutes. We found good agreement between Speckle Tracking Ultrasound and sonomicrometry in the in vitro model. Best agreement was 0.83 ± 0.70%. Worst agreement was -1.13 ± 6.46%.
It has been shown possible to automate a model that can be used for evaluating the in vitro accuracy and precision of ultrasound modalities measuring deformation. Sonomicrometry and Speckle Tracking Ultrasound had acceptable agreement.
PMCID: PMC2944150  PMID: 20822532
14.  Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS) 
Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described.
Obtaining competence in ICU echocardiography may be achieved in different ways – either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level – obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.
PMCID: PMC2586628  PMID: 18837986
15.  A Porcine Pneumothorax Model for Teaching Ultrasound Diagnostics 
Academic Emergency Medicine  2012;19(5):586-592.
Objectives: Ultrasound (US) is a sensitive diagnostic tool for detecting pneumothorax (PTX), but methods are needed to optimally teach this technique outside of direct patient care. In training and research settings, porcine PTX models are sometimes used, but the description of the PTX topography in these models is lacking. The study purpose was to define the distribution of air using the reference imaging standard computed tomography (CT), to see if pleural insufflation of air into a live anaesthetized pig truly imitates a PTX in an injured patient.
Methods: A unilateral catheter was inserted into one pleural cavity of each of 20 pigs, and 500 mL of air was insufflated. After a complete thoracic CT scan, the anterior, lateral, medial, basal, apical, and posterior components of the PTXs were compared. The amount of air in each location was quantified by measuring the distance from the lung edge to the chest wall (LE-CW). A supine anteroposterior chest radiograph (CXR) was taken from each model and interpreted by a senior radiologist, and the image results were compared to CT.
Results: All 20 hemithoraces with PTX were correctly identified by CT, while six remained occult after interpreting the CXRs. The PTXs were anterior (100%), lateral (95%), medial (80%), basal (60%), apical (45%), and posterior (15%). The major proportion of the insufflated 500-mL volume was found in the anterior, medial, and basal recesses.
Conclusions: The authors found the distribution of the intrathoracic air to be similar between a porcine model and that to be expected in human trauma patients, all having predominantly anterior PTX topographies. In a training facility, the model is easy to set up and can be scanned by the participants multiple times. To acquire the necessary skills to perform thoracic US examinations for PTX, the porcine models could be useful.
PMCID: PMC3502747  PMID: 22594363

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