Hand-carried echocardiography for assessment of left ventricular filling and ejection fraction in the surgical intensive care unit

Dustin G Mark, Geoffrey E Hayden, Bonnie Ky, Anna Paszczuk, Monica Pugh, Shannon Matthews, Annamarie Horan, Vicente H Gracias, James N Kirkpatrick, Anthony J Dean
Journal of Critical Care 2009, 24 (3): 470.e1-7

PURPOSE: To better define the reliability of left ventricular ejection fraction (LVEF) and left ventricular filling, as determined by either hand-carried ultrasound (HCU) or formal transthoracic echocardiography (TTE), in the critically ill surgical patient.

MATERIALS AND METHODS: Prospective cross-sectional study of 80 surgical intensive care unit patients with concomitant (<30 minutes apart) formal TTE and clinician-performed cardiac HCU. Visual estimates of LVEF and left ventricular filling ("underfilled" vs "normally filled") were recorded, both by clinicians performing HCU and fellowship-trained echocardiographers.

RESULTS: Bland-Altman plot analysis of LVEF estimates revealed good interobserver agreement between HCU and formal TTE (% LVEF mean bias, -2.2; with 95% limits of agreement, +/-22.1). This was similar to agreement between independent echocardiography observers (% LVEF mean bias, 1.3; with 95% limits of agreement, +/-21.0). However, assessments of left ventricular filling demonstrated only fair to moderate interobserver agreement (kappa = 0.22-0.40). Of note, a greater percentage of the 5 standard acoustic windows were obtainable using formal TTE (72% vs 56%).

CONCLUSIONS: Formal TTE offers no advantage over HCU for determination of LVEF in critically ill surgical patients, even though the former allows for a more complete examination. However, estimations of left ventricular filling only demonstrate fair to moderate interrater agreement and thus should be interpreted with care when used as markers of volume responsiveness.

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