Novice Physician Ultrasound Evaluation of Pediatric Tricuspid Regurgitant Jet Velocity

Zachary W Binder, Sharon E O'Brien, Tehnaz P Boyle, Howard J Cabral, Sepehr Sekhavat, Joseph R Pare, Zachary W Binder, Sharon E O'Brien, Tehnaz P Boyle, Howard J Cabral, Sepehr Sekhavat, Joseph R Pare

Abstract

Introduction: Pulmonary hypertension, associated with high mortality in pediatric patients, is traditionally screened for by trained professionals by measuring a tricuspid regurgitant jet velocity (TRJV). Our objective was to test the feasibility of novice physician sonographers (NPS) to perform echocardiograms of adequate quality to exclude pathology (defined as TRJV > 2.5 meters per second).

Methods: We conducted a cross-sectional study of NPS to assess TRJV by echocardiogram in an urban pediatric emergency department. NPS completed an educational course consisting of a didactic curriculum and hands-on workshop. NPS enrolled a convenience sample of patients aged 7-21 years. Our primary outcome was the proportion of echocardiograms with images of adequate quality to exclude pathology. Our secondary outcome was NPS performance on four image elements. We present descriptive statistics, binomial proportions, kappa coefficients, and logistic regression analysis.

Results: Eight NPS completed 80 echocardiograms. We found 82.5% (95% confidence interval [CI], 74.2-90.8) of echocardiograms had images of adequate quality to exclude pathology. Among image elements, NPS obtained a satisfactory, apical 4-chamber view in 85% (95% CI, 77.1-92.9); positioned the color box accurately 65% (95% CI, 54.5-75.5); optimized TRJV color signal 78.7% (95% CI, 69.8-87.7); and optimized continuous-wave Doppler in 55% (95% CI, 44.1-66.0) of echocardiograms.

Conclusion: NPS obtained images of adequate quality to exclude pathology in a majority of studies; however, optimized acquisition of specific image elements varied. This work establishes the basis for future study of NPS assessment of TRJV pathology when elevated pulmonary pressures are of clinical concern.

Conflict of interest statement

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Figures

Figure 1
Figure 1
Tricuspid regurgitant jet velocity curriculum.
Figure 2
Figure 2
Tricuspid regurgitant jet velocity image elements. 2A. Apical 4-Chamber, 2B. Color box positioning, 2C. Tricuspid regurgitant jet signal optimization, 2D. Continuous-wave Doppler interrogation.
Figure 3
Figure 3
Flowchart demonstrating patient enrollment and image rating as determined by pediatric cardiologist. ★Seven patients were scanned by two sonographers. TRJ, tricuspid regurgitant jet; m/s, meters per second.

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