key: cord-0911320-fqiu6j5k authors: Lu, Jing; Lin, Jun; Yin, Lixue; Shi, Rui; Li, Huanxing; Ge, Yang; Luo, Jing title: Using remote consultation to enhance diagnostic accuracy of bedside transthoracic echocardiography during COVID‐19 pandemic date: 2021-05-31 journal: Echocardiography DOI: 10.1111/echo.15124 sha: 4ba60a1204a2c60ff3b7ba57e4d65ee8291a074e doc_id: 911320 cord_uid: fqiu6j5k OBJECTIVE: The aim of this study was to evaluate the clinical significance of remote consultation over bedside transthoracic echocardiography (RC‐B‐TTE) for patients with coronavirus disease 2019 (COVID‐19). METHODS: Five frontline echocardiographers performed and interpreted B‐TTE for 30 patients with COVID‐19 in the isolation wards, and the on‐site B‐TTE reports (OSR) were generated. Then remote consultation over the 30 B‐TTE studies was conducted by two experienced echocardiographic consultants while blinded to the OSR, and the corresponding remote consultation reports (RCR) were generated. Subsequently, the five frontline echocardiographers were convened together to discuss the difference between the OSR and RCR, and to confirm the correct interpretation and the misdiagnosis using a “majority‐vote” consensus as the diagnostic “gold standard”. Afterwards the reasons for the misdiagnosis were given by the frontline echocardiographers themselves. The inter‐rater agreement between the OSR and the “gold standard” was assessed using Kappa coefficient and percent agreement. RESULTS: Complete correctness of the 30 copies of the RCR were determined by the 5 frontline echocardiographers. The reliability of the OSR in the findings of cardiac chamber dilation, left ventricular hypertrophy and pulmonary hypertension were weak (Kappa <0.6). The reliability of the OSR in the recognition of major cardiac abnormalities was very weak (Kappa =0.304, percent agreement =63.3%). Misdiagnosis of major abnormalities was found in 11 copies of OSR (11/30, 36.7%). CONCLUSIONS: The protocol of RC‐B‐TTE has shown noticeable superiority in ameliorating diagnostic accuracy of echocardiography, which should be generalized to clinical practice during the COVID‐19 or similar pandemic. Coronavirus disease 2019 (COVID-19) is a highly infectious, lethal and serious threat to human health. The cardiac injury occurred in many patients with COVID-19, 1-4 and the incidence was recorded as high as 27.8%. 5 Studies showed that most critical COVID-19 patients with underlying cardiovascular diseases exhibited a higher morbidity and mortality. 4, 6, 7 Therefore, it is crucial to discover the possible cardiac abnormalities promptly and effectively to facilitate treatment decision for the patients with COVID-19. Using remote consultation or telemedicine in disasters and public health emergencies has been confirmed to be very useful by previous studies. [8] [9] [10] [11] At the early phase of the COVID-19 outbreak, the medical members of Ultrasound Medicine of Chinese Medical Association proposed implementing the protocol of remote consultation over bedside transthoracic echocardiography (RC-B-TTE) into daily clinical practice to optimize the application during the pandemic. 12, 13 Theoretically, echocardiographic diagnostic accuracy and quality control can be ensured with a collective wisdom of experienced echocardiographic experts via remote consultation. However, this theoretical advantage of the RC-B-TTE during the pandemic is still to be confirmed. Thus, the aim of this study was to evaluate the clinical significance of RC-B-TTE for patients with COVID-19. This study was conducted according to the World Medical image were acquired through the left parasternal long-axis view, parasternal short-axis views (including aortic root, pulmonary artery, mitral orifice, left ventricular papillary muscle, and apical short-axis views), apical views (including apical two-, three-, four-, and fivechamber views), subcostal views (including four-chamber view, longaxis view of inferior vena cava). The measurement of dimensions and velocities, and the cardiac chamber quantification and ventricular systolic and diastolic function assessment were completed on the echocardiographic machine according to the recommendations. 12, 13 Then the OSR was produced by the frontline echocardiographers based on their personal experience and echocardiographic expertise. [12] [13] [14] [15] [16] The images were replayed using a medical DICOM viewer, and the dimensions and velocities were remeasured. The remote consultation reports (RCR) for each B-TTE were jointly generated by the two echocardiographic consultants based on both their visual assessment and the measurements. All of the 5 frontline echocardiographers and the two echocardiographic consultants were qualified Chinese Medical Practitioner of Ultrasonography. Among the five frontline echocardiographers, three doctors were attending physicians and two doctors were associate chief physicians. The two echocardiographic consultants were associate chief physician and chief physician respectively. All the seven doctors had more than 5 years of experience in performing and interpreting echocardiography. The main difference was that the two echocardiographic consultants could perform various special echocardiography procedures (ie, transesophageal, stress, and intraoperative echocardiography), while the five frontline echocardiographers could not. Moreover, the two echocardiographic consultants were more familiar with the relevant international echocardiographic recommendations and guidelines 14-16 than the five frontline echocardiographers. According to the recommendations for quality echocardiography laboratory operations, 17 13 basic fields describing cardiac anatomy and function were rated as either "NORMAL" or "ABNORMAL" for every OSR and RCR. Then, 11 types of specific cardiac abnormalities were summarized for every OSR and RCR. Subsequently, the five frontline echocardiographers were convened together to discuss and confirm the difference in the 13 basic fields and the 11 types of specific cardiac abnormalities between the OSR and RCR. A "majority-vote" consensus was used as the diagnostic "gold standard", against which the correct interpretation and the misdiagnosis of the B-TTE were determined. The "majority-vote" consensus defined as no less than 3 out of the 5 frontline echocardiographers had consistent votes on the B-TTE diagnosis. Afterward the reasons for the misdiagnosis were given by the frontline echocardiographers themselves. Statistical analyses were performed using SPSS 16.0 (SPSS). Categorical variables were expressed as a case (percentage). Continuous variables with normal distribution were summarized as mean ± standard deviation, and those without normal distribution were summarized as median (interquartile range). The inter-rater agreement between the OS-R and "gold standard" was analyzed using Kappa tests and percent agreement analyses. The difference was considered as statistical significance when P is less than .05. Table 1 . The oxygen treatments were applied to 21 patients, and four of them underwent mechanical ventilation. Complete correctness of the 30 copies of the RCR was determined by the five frontline echocardiographers themselves using "majorityvote" consensus. Thus, the diagnosis recorded in the RCR was confirmed as the "gold standard", against which the diagnostic reliability of the OSR was assessed. The diagnostic agreement on the 13 basic fields of cardiac anatomy and function between the OSR and RCR in 30 patients with COVID-19 were shown in Table 2 . The reliability of the OSR was weak in the diagnosis of abnormalities in right ventricle, right atrium, aorta, pulmonary artery, and interventricular septum (Kappa <0.6). The diagnostic agreement on the findings of specific echocardiographic abnormalities between the OSR and RCR of B-TTE of the 30 patients with COVID-19 were shown in Table 3 . The reliability of the OSR in findings of cardiac chamber dilation, left ventricular hypertrophy and pulmonary hypertension were weak (Kappa <0.6). The reliability of the OSR in the recognition of major cardiac abnormalities was very weak (Kappa =0.304, percent agreement =63.3%). According to the results of the "majority-vote" consensus, misdiagnosis of major abnormalities was found in 11 copies of OSR (11/30, Invasive mechanical ventilation, n (%) 2 (6.67) Note: Fever was defined as temperature ≥37.3 ℃. PaO2/FiO2, the ratio of arterial oxygen partial pressure to fractional inspired oxygen; CK-MB, isoenzyme MB of creatine kinase; NT-proBNP, amino-terminal pro-brain natriuretic peptide; hs-cTnT, high-sensitivity troponin T. The diagnostic agreement on the 13 basic fields describing cardiac anatomy and function as "Normal" or "Abnormal" between the on-site reports (OSR) and remote consultation reports (RCR) of bedside transthoracic echocardiography (B- The B-TTE plays an important role in providing clinicians with essential information about the cardiac structure, hemodynamics, and function. However, the on-site B-TTE interpretation might be distorted to some extent due to the personal experience and level of expertise in echocardiography, the harsh working condition of COVID-19 isolation wards, and the cumbersome personal protective equipment. The most notable result of this study was that the on-site interpretation had missed some crucial cardiac abnormalities in the B-TTE images. The misdiagnosis included pulmonary embolism, right heart enlargement, pulmonary hypertension, thickened LV wall, and small pericardial effusion. These cardiac abnormalities have been proved very important for treatment decision-making. For instance: pulmonary embolism is closely associated with hemodynamic instability and mortality of the patients with COVID-19, 18 right heart has been supposed to be in the eye of the COVID-19 storm, 19 and Uncertainty, might be affected by some above-mentioned factors. Abbreviations as in Table 2 and 3. The misdiagnosis of the on-site B-TTE reports and the possible reasons from the 5 frontline echocardiographers themselves F I G U R E 4 Narrowed operable space of the COVID-19 isolation wards. Legend: This photograph shows that a front-line echocardiographer was performing bed-sideechocardiography for a COVID-19 patient in an isolation ward. The images acquisition and interpretation might had been affected by several factors, such as the heavy personal protective equipment and the narrowed operable space frontline echocardiographers expressed that the personal protective equipment might have affected the B-TTE image acquisition, the echocardiographic measurement, and interpretation. Thirdly, severe and critical patients with COVID-19 are usually unable to coordinate into a special position, which might prevent echocardiographers from obtaining the standard cardiac views. Fourthly, the equipment and other facilities in the isolation wards could also interference with the B-TTE image acquisition and interpretation. Lastly, in China, an echocardiographer often needs to serve a large number of patients, so the time allocated to each patient is limited. In this study, some frontline echocardiographers implied that due to limited working hours, it was difficult for them to carefully analyze and interpret all the echocardiographic views described in the recommendation. 12, 13 Therefore, it is necessary and imperative for echocardiography-related staff to seek a better B-TTE workflow to obtain reliable B-TTE diagnostic information during the pandemic. Evolving telemedicine technology has created many possibilities for clinical practice. 10, 11 Some of these telemedical services have already had a significant impact on medical practice in developed countries, notably tele-echocardiography. 21 The remote diagno- As a useful protocol for investigating cardiac pathophysiology on remotely-located patients, tele-echocardiography has been widely used in developed countries. 24 Pilot studies showed that 5G-based robot-assisted teleultrasonography is a new feasible strategy for real-time cardiopulmonary assessment during COVID-19 pandemic. 29, 30 In these studies, robots replaced the frontline ultrasonographers to obtain the parasternal long-axis view and cardiac apical four-chamber view, and brief echocardiographic assessments were realized. These strategies can help both frontline doctors and remote consultants avoid exposure to the deadly infectious virus. But at present, the robot has not been able to perform a comprehensive echocardiographic examination. This study found that some very simple but crucial important cardiac abnormalities were missed by the on-site echocardiographic interpretation in the COVID-19 isolation wards; although the frontline echocardiographers were not novices, and also not poorly trained or completely inexperienced staff. On the contrary, RC-B-TTE has shown noticeable superiority in ameliorating diagnostic accuracy over the on-site interpretation from the frontline echocardiographers. As an important field of telemedicine, the protocol of RC-B-TTE or tele-echocardiography has obviously technical superiority and should be generalized to clinical practice during the COVID-19 or similar pandemic without delay. The authors would like to thank the participants, as well as the contribution that the frontline medical workers have made. No competing financial interests exist. Lixue Yin and Jun Lin made equally essential contribution to this work, thus we list both of them as co-corresponding author. All authors have significant contribution to this work. The data that support the findings of this study are available from the corresponding author upon reasonable request. Jing Lu https://orcid.org/0000-0001-7602-5122 COVID-19 and the cardiovascular system Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic COVID-19, ACE2, and the cardiovascular consequences Cardiovascular complications in COVID-19 Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19) COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options Cardiovascular complications in patients with COVID-19: consequences of viral toxicities and host immune response Telehealth in the times of SARS-CoV-2 infection for the otolaryngologist Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19) State of Telehealth Virtually perfect? Telemedicine for Covid-19 Chinese recommendations for the implementation of bedside echocardiography and remote consultation in patients of COVID-19 Chinese recommendations for the implementation of bedside echocardiography and remote consultation in patients with coronavirus disease 2019 Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging 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 Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography American Society of Echocardiography recommendations for quality echocardiography laboratory operations Pulmonary embolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: a narrative review In the eye of the storm: the right ventricle in COVID-19 Myocardial Inflammation and Dysfunction in COVID-19-Associated Myocardial Injury Tele-echocardiography -made for astronauts, now in hospitals Tele-echocardiography: enhancing quality at the point-of-care Feasibility and accuracy of tele-echocardiography, with examinations by nurses and interpretation by an expert via telemedicine, in an outpatient heart failure clinic Assessment and analysis of territorial experiences in digital tele-echocardiography A web based health technology assessment in tele-echocardiography: the experience within an Italian project Remote diagnosis of congenital heart disease in southern Arizona: comparison between tele-echocardiography and videotapes The evolution of pediatric teleechocardiography: 15-year experience of over 10,000 transmissions Implementation of a statewide, multisite fetal tele-echocardiography program: evaluation of more than 1100 fetuses over 9 years Feasibility of a 5G-based robot-assisted remote ultrasound system for cardiopulmonary assessment of patients with coronavirus disease 2019 Pilot study of robot-assisted tele-ultrasound based on 5G network: a new feasible strategy for early imaging assessment during COVID-19 pandemic Using remote consultation to enhance diagnostic accuracy of bedside transthoracic echocardiography during COVID-19 pandemic