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Table 4 Characteristics of ultrasound skill assessment and overall findings for 23 included studies

From: Ensuring competency in focused cardiac ultrasound: a systematic review of training programs

  SUBJECTS ASSESSED   FINDINGS
Views Pathology Assessed Comparator
Alexander 2004 [36] 533 patients (mixed: ICU, intermediate care unit, clinic) PLAX, PSAX, A4 (+ color doppler) LV function (EF), MR, aortic valve mobility, pericardial effusion TTE performed by experienced sonographer and interpreted by echocardiographer, as assessed by experienced observer Acquisition: learners obtained satisfactory images to assess LV function in 98.7% of patients, MR in 92.7%, aortic valvular disease in 89.7%, and pericardial effusions in 97.9% Interpretation: learners showed fair agreement with TTE for identifying MR (κ = 0.31), aortic valvular disease (κ = 0.31) and moderate agreement for pericardial effusion (κ = 0.51) and LV dysfunction (κ = 0.51)
Beraud 2013 [37] 5 simulated cases PLAX, PSAX, A4, SC4, IVC LV function, RV dilation, RV function, pericardial effusion Simulator performance by novice medical students and expert sonographers Acquisition: novices took longer to scan (358 ± 170s) than fellows (136 ± 63s), and fellows took longer than experts (38 ± 6s) Interpretation: one diagnosis (RV dysfunction) was missed by one fellow (5.5%) + 3 novices (33%); experts were significantly faster (18 ± 7s) than fellows (72 ± 38s), who were significantly faster than novices (185 ± 86s)
Caronia 2013 [38] 102 patients (mixed: ICU, intermediate care unit) PLAX, PSAX, A4, SC4 (+ color doppler) LV function (EF, WMAs), RV strain or diastolic collapse, septal defects, valvular lesions, thrombi, aneurysm, pericardial effusion Findings on TTE performed by sonographer and interpreted by cardiologist, as assessed by a trained fellow Interpretation: learners correctly identified 95% of patients with systolic dysfunction (κ = 0.67), 85% of patients with pericardial effusion (κ = 0.60), but only 41% patients with RV strain (κ = 0.38); valvular pathologies were identified with moderate agreement (κ = 0.50 - 0.52) as were WMAs (κ = 0.49)
Carrie 2015 [39] 180 ED patients PLAX, PSAX, A4, SC4, IVC, lung, abdomen LV size (LVH) + function, RV dilation, IVC size, pericardial effusion, pleural effusion, consolidations, interstitial fluid, abdominal pathology Focused exam performed by experienced physician board-certified in ultrasound or echocardiography Acquisition: learners took longer to perform exams than experts, but exam time decreased from 14.5 min (0-10 exams performed) to 10 min (10-20 exams) to 8 min (20-30 exams), while experts required 4-6 min for exams Interpretation: agreement with experts improved when comparing learner performance over the first 10 exams performed (exams 0-10) with the last 10 exams performed (exams 20-30) for assessment of LV function (κ=0.77 to κ=0.92), LVH (κ=0.67 to κ=0.9), IVC dilation (κ=0.6 to κ=0.88) and collapse (κ=0.3 to κ=0.76), while agreement peaked after completion of 10-20 exams for assessing RV dilation (κ=0.78 to κ=0.83) and pericardial effusion (κ=0.74 to κ=0.9)
Chisholm 2013 [40] 1 healthy volunteer PLAX, PSAX, A4, SC4, IVC none Evaluation of images by cardiologist board-certified in echocardiography Acquisition: 85% were able to achieve acceptable PLAX + PSAX views within 120s, 70% and 57% were able to achieve SC4 and A4 views (respectively), and <50% obtained IVC view; SC4 and A4 views were more likely to be obtained by those who completed > 45 practice studies
Croft 2006 [41] 72 clinic patients PLAX, PSAX, A4, A2 (+ color doppler) LV size + function (WMAs, LVH), valvular lesions, pericardial effusion Focused exam performed by a level 3 certified echocardiographer Acquisition: learners obtained diagnostic images in 94% of patients; A2 view was most difficult and was imaged adequately in 68% of patients while PLAX, PSAX, and A4 were imaged adequately in 96%, 92%, and 94%, respectively Interpretation: learners correctly identified 93% of major findings (PPV = 93%, NPV = 99%) and 78% of minor findings (PPV = 97%, NPV = 93%)
Farsi 2017 [42] 205 ED patients PLAX, PSAX, A4, SC4 LV function (EF by EPSS or Quinones equation, WMAs), RV dilation, pericardial effusion Findings on TTE performed by a cardiologist Interpretation: all major pathologies were identified with >90% accuracy and with near perfect agreement to cardiologists, including low LVEF (κ=0.85), WMAs (κ=0.83), RV dilation (κ=0.86) and pressure overload (κ=1.00), + pericardial effusion (κ=0.83)
Ferrada 2011 [43] 51 ICU patients PLAX, PSAX, A4, SC4, IVC LV function, IVC size, pericardial effusion TTE performed and interpreted by a cardiologist Acquisition: the A4 was the only view that could not be obtained in all patients (84.3%) Interpretation: there was 100% correlation between learners and cardiologists on global heart function and contractility
Gaudet 2016 [44] 36 ICU patients PLAX, PSAX, A4, SC4, IVC (+ M-mode) none Performance on 1st and 2nd exams, 10th and 11th exams, and 19th and 20th exams as assessed by a level 3 certified intensivist Efficiency: efficiency improved incrementally after the first 10 studies (1.55 to 2.48) and by a greater extent than after 10 to 20 studies (2.48 to 2.61); efficiency was lower for trainees compared to experts at all intervals Workload: mental and physical demand, time, effort, frustration, and anxiety decreased throughout all assessment intervals, with the greatest reduction after completing the first 10 studies
Hellmann 2005 [45] 229 floor patients PLAX, PSAX, A4, A2 (+ color doppler) LV size (thickness) + function, septal thickness, LA size, valvular lesions, pericardial effusion, aortic size Review of TTE and focused exam by an experienced, level 3 certified cardiologist Acquisition: image acquisition improved over time as more scans were completed (up to 22 scans); the A2 view had the slowest rate of learning while the PSAX was learned at the fastest rate Interpretation: interpretation accuracy improved over time when performing up to 22 scans; measurement of LV diastolic size and identification of pericardial effusions were learned fastest while identifying AS, MR, and measuring septal wall thickness had the slowest rate of learning
Johnson 2016 [46] 178 patients (mixed: ICU, intermediate care unit, floor) PLAX, PSAX, A4 or A5, A2, ALAX, SC4 LV function TTE performed by trained sonographer and interpreted by a level 2 or 3 certified cardiologist Acquisition: 100% of learner-performed exams were adequate to characterize LV systolic function Interpretation: learners identified impaired LV function with substantial agreement (κ=0.77, sens=0.91, spec=0.88) with experts, similar to the interobserver variability among echocardiographers within the study institution (κ=0.78); learners had the lowest sens and spec for identifying mild/moderate LV dysfunction (sens=0.70, spec=0.86)
Labbe 2016 [47] 115 ICU patients PLAX, PSAX, A4, SC4, IVC (+ color, pw, cw doppler) LV function (EF, WMAs, LV outflow tract velocity time integral, filling pressure, E/A + E/e' ratio), AV, MV, RV dilation, IVC size, pericardial effusion Focused exam performed by a level 3 certified cardiologist, as assessed by two independent cardiologists Acquisition: learners in the shorter training group obtained at least one optimal view in 83% of exams, compared to 91% by those who received additional training, while experts obtained at least one optimal view in 98% and 94% of exams; no difference in exam duration between the 2 learner groups (22±8 min, 22±10 min, respectively), but both groups took longer than experts to perform exams (12±6 min, 13±7 min) Interpretation: learners in the shorter training group had more unanswered questions than experts (13% vs 7%), while those with additional training had a similar # of unanswered questions as experts (9% vs 8.5%); those who received additional training interpreted RV dilation, valvular pathology, and calculated aortic peak velocity, E/A ratio, and E/e' ratio with greater accuracy than those who received shorter training
108 ICU patients Above plus septal deviation
Lucas 2009 [48] 314 patients (mixed: ICU, floor, short stay unit) PLAX, PSAX, A4, A2, IVC LV size + function (LVH), MR, LA size, IVC size, pericardial effusion TTE performed by experienced sonographers and interpreted by a level 2 echocardiograpy certified cardiologist Acquisition: leaners were able to obtain adequate imaging on 94-98% of intended assessments Interpretation: learners were best at identifying severe MR (sens = 100%, spec = 83%), pericardial effusions (sens = 100%, spec = 95%), LA dilation (sens = 90%, spec = 74%), LV dysfunction (sens = 85%, spec = 88%), and less skilled at identifying LVH (sens = 70%, spec = 73%) and dilated IVC (sens = 56%, spec = 86%)
Manasia 2005 [49] 90 ICU patients PLAX, PSAX, A2, A4 LV function (WMAs), pericardial effusion Focused exam performed by cardiologist, and assessment of learners’ images by a cardiologist Acquisition: learners were able to successfully perform a TTE exam in 94% of patients Interpretation: 84% of exams were correctly interpreted by learners
Martin 2007 [50] 354 floor patients PLAX, PSAX, A4, SC4 (+ color, pw doppler) LV size (wall thickness) + function (E/A ratio), LA size, valvular lesions, vegetations, pericardial effusion, aortic size Image quality on focused TTE performed by echocardiography technician, assessed by an independent cardiologist and compared against TTE; interpretation of pre-recorded focused exams by cardiology fellows Acquisition: learners obtained less optimal images than technicians across all views (80.6% agreement with TTE image quality vs 98.9% agreement), particularly on the A4 view (difference of 33.6%) Interpretation: learner measurements were less accurate than technicians (80.2% vs 89.9% agreement); learners were best at assessing aortic root size + diastolic LV size (differences of 5.6% and 6.5%, respectively) and least accurate for systolic LV size (13.1% difference); cardiology fellows were no better than learners at interpreting E/A ratio, MR, and AS but were more skilled at interpreting LV function, AR, pericardial effusions, and vegetations
Mjolstad 2013 [51] 199 floor patients PLAX, PSAX, A4, A2, ALAX, IVC, lung (+ color doppler) LV function (WMAs), RV function (systolic excursion), RV dilation, septal flattening, valvular lesions, LA size, IVC size, pericardial effusion, aortic size TTE performed by cardiologist or to findings on computed tomography imaging for detection of pleural effusion and aortic size Acquisition: learners were able to assess LV function, pericardial effusion, + pleural effusions in >95% of patients, were able to assess RV function, LA size, MV, + AV in > 85% of patients, TV + IVC in > 75% of patients, and abdominal aorta + PV in only 50% and 49% of patients, respectively Interpretation: learners interpreted LV function, pleural effusions, and pericardial effusions with very strong correlation with experts (r ≥ 0.83); AS, AR, + aortic aneurysms with strong correlation (r ≥ 0.67); WMAs, LA dilation, IVC size, TR, and MR with moderate correlation (r ≥ 0.53)
Mozzini 2014 [52] 15 floor patients PLAX, PSAX, A4, SC4, IVC, supra-sternal LV size + function, RV dilation, IVC size, pericardial effusion TTE performed by sonographer and interpreted by either a cardiologist or a hospital certified in echocardiography Acquisition: students who received 18 hours of training were more skilled at obtaining parasternal and apical views compared to those who received only 9 hours; learners required longer (7±1 min) to perform each exam during the first 3 days compared to the second 3 days (4±0.5 min) Interpretation: students who received 18 hrs of training were more skilled at interpretation compared to those who received 9 hrs; after 18 hrs learners showed substantial agreement with experts on identifying pericardial effusions (κ=0.71), global LV function (κ=0.2 to 0.77), + atrial size (κ=0.66), moderate agreement for LV (κ=0.54) + RV (κ=0.56) enlargement and valvular pathology (κ=0.56), and fair agreement for IVC size (κ=0.35), WMAs (κ=0.35), + aortic size (κ=0.28)
30 floor patients Above + M-mode, color doppler LV size + function (EF by Simpson's method, WMAs, MAPSE), RV size + function, valvular lesions, IVC size, pericardial effusion, aortic size
Ruddox 2013 [53] 303 ICU or ED patients A4, A2, ALAX LV size + function (EF, WMAs), RV function, LA size, valvular lesions, aortic dilation, IVC size, pericardial effusion Findings on focused exam performed by a level 3 certified echocardiographer Interpretation: learners identified LVEF < 40% (κ = 0.53), LV dilation (κ = 0.43), WMAs (κ = 0.64), pericardial effusion (κ = 0.4), valvular abnormalities (avg κ = 0.43), + dilated IVC (κ = 0.17); overall accuracy improved over time from 0-9 exams performed (κ = 0.22) to 20-29 exams performed (κ = 0.38), and only marginally after 30-35 exams (κ= 0.41)
Ruddox 2017 [54] 60 floor patients PLAX, A4 (+ color doppler) LV size + function (EF, WMAs), MR, AR, aortic dilation, pericardial effusion Findings on focused exam performed by a level 3 certified echocardiographer Interpretation: learners identified LVEF < 40% (κ = 0.7), LV dilation (κ = 0.75), and LA dilation (κ = 0.66) with substantial agreement with TTE, RV pathology (κ = 0.42-0.48), MR (κ = 0.56), and WMAs (κ = 0.44) with moderate agreement, and pericardial effusion (κ = 0.30) + AR (κ = 0.35) with fair agreement
See 2014 [55] 318 ICU patients PLAX, PSAX, A4, SC4, IVC (+ M-mode, color doppler) LV function (EF by Simpson's method), RV dilation, MR, IVC size, pericardial effusion Review of images by an intensivist experienced in critical care ultrasound Acquisition: views obtained improved from 40% acceptable after 1-10 exams to 91% acceptable after at least 30 exams; learners took 21.3 ± 9.5 min for each exam and 18.9 ± 7 min for each after the first 30 studies; scanning duration decreased by 0.14 min (CI 0.10 - 0.18 min) after each successive study Interpretation: pathologies were accurately assessed in > 80% after 11-20 exams, and > 90% after 30 exams for all pathologies except for estimation of LVEF fraction (85% after 30 exams)
Smith 2018 [56] 3 standardized patients PLAX, PSAX, A4, SC4, IVC none Focused exam performed by a level 1 certified cardiology fellows and by experienced sonographers, interpreted by cardiologists (2 independent evaluators) Acquisition: learners obtained comparable quality images as fellows for PLAX and SC4 views, but fellows obtained higher quality images for PSAX, A4, and IVC views; learners and fellows exam durations were similar (15.3 min and 13.8 min, respectively) Efficiency: there was no difference in efficiency between learners and senior cardiology fellows, but experts consistently performed better than cardiology fellows and learners
Vignon 2010 [57] 201 ICU patients PLAX, PSAX, A4, SC4, IVC LV size + function (EF, WMAs), RV size + function, IVC size, pericardial effusion Focused exam performed by an experienced, level 3 certified intensivist Acquisition: leaners performed longer exams than experts (7±2.5 min vs 3±1 min) and obtained fewer views (82% vs 88%); image quality was significantly better when performed by experts for the PSAX view and similar (good to excellent) for all others Interpretation: learners had perfect agreement with experts in identifying tamponade (κ=1), near-perfect agreement when interpreting LV function (κ=0.84) and LV dilation (κ=0.90), and substantial agreement for identifying RV dilation (κ=0.76), IVC dilation (κ=0.79) and collapse (κ=0.66), + pericardial effusion (κ=0.79)
Yan 2010 [58] 107 patients (mixed: floor, clinic) PLAX, PSAX, A4, SC4 (+ color doppler) Valvular lesions Findings on focused exam performed by trained nurse or cardiologist Interpretation: learners had moderate agreement (κ=0.45) with experts when identifying valvular findings and were most skilled at identifying MS, MR, and AS, and substantially less skilled at identifying AR (κ=0.23)
  1. Certification levels of experts used for comparison were noted if specified in the text and refer to the ACC/ASE certification levels (see Table 1). Italicized studies reported kappa agreement values for LV systolic function and/or pericardial effusion and were therefore included in quantitative analysis.
  2. PLAX Parasternal long axis, PSAX Parasternal short axis, A4 Apical 4-chamber, SC4 Subcostal 4-chamber, IVC Inferior vena cava, A2 Apical 2-chambere, ALAX Apical long axis (apical 3-chamber), pw Pulsed wave, cw Continuous wave, LV Left ventricle, EF Ejection fraction, MR Mitral regurgitation, RV Right ventricle, WMAs Regional wall motion abnormalities, LVH Left ventricular hypertrophy, EPSS E-point septal separation, AV Aortic valve, MV Mitral valve, LA Left atrium, AR Aortic regurgitation, MAPSE Mitral annular plane systolic excursion, RVSP Right ventricular systolic pressure, ICU Intensive care unit, ED Emergency department, LVEF Left ventricular ejection fraction, HTN Hypertension, sens Sensitivity, spec Specificity, κ Cohen’s kappa coefficient