HeartWeb

HEARTscan (Haemodynamic Echocardiographic Assessment in Real Time)
General Information

Welcome to the course. In this guide, I will outline the development of the course, give a course overview, and supply basic instructions on how to use the material on DVD-ROMs and in the work booklet. HEARTscan is a trade mark.

1. Historical Development of This Course

Echocardiography has seen a meteoric rise in use in ultrasound since the mid-1990s in Australia, and around the world in general. When we started with echocardiography, it was predominantly for use in cardiac surgery with transoesophageal echocardiography. Because the anaesthetist has to make calls on complex issues such as mitral valve repairs, the level of knowledge expected for an anaesthetist practising echocardiography was "as good as a cardiologist". As a craft group, we have encountered considerable opposition from competitive sectors in being able to perform intra-operative echocardiography, to the point, that there has been considerable pressure on rebates to limit the use of ultrasound in anaesthesia. The need to be fully trained in echocardiography has meant that only a limited section of anaesthesia has had exposure to transoesophageal echocardiography, and because of this, many noncardiac anaesthetists have felt excluded from the use of this technology in their practice.

As a practicing cardiac anaesthetist, one has to pursue a process of echocardiography education that is similar in complexity and magnitude to sitting a second fellowship exam. This has been facilitated by educational activities within Australia, culminating in the production of the Post Graduate Diploma of Perioperative and Critical Care Echocardiography run through the University of Melbourne. http://www.heartweb.com.au

It has become apparent to us for a while, though, that for noncardiac anaesthetists, intensive care physicians, and emergency medicine physicians, that the method of getting into echocardiography is "back to front". If you have to be "as good as the cardiologist" in order to practice echocardiography, and yet you may not need the full extent of that knowledge in your practice, then it becomes a considerable disincentive to enter the world of ultrasound. Furthermore, there are many uses of ultrasound other than echocardiography for the critical care physician. In trauma, we have seen the FAST examination become widespread, and there are now a number of publications showing the benefit of ultrasound in performing regional anaesthesia, and in guiding the placement of vascular devices. In many ways, the perioperative clinician needs to be "part radiologist" and "part cardiologist". The other premise is that limited ultrasound information may still be extremely useful in guiding your anaesthetic, intensive care, or emergency management of patients; and may be considerably more useful than not having that available at all.

Limited echocardiography is really not a totally new concept. There are publications looking at the use of limited echocardiography to assess volume or systolic function or as a screening tool to rule out severe aortic stenosis. Haemodynamic state assessment is a concept that we have championed through the PGDipEcho and our Point of Care ultrasound courses. What we want to achieve is to strike a balance between “too little and too much”. In doing so, our group analysed what is the most important information we need for the critical care environment, in order to influence how we will manage patients. Also, a limited study should be non-invasive and brief so that it does not interfere with all the other aspects of providing critical care management whether that is in the OR, ICU or ED.

In ranking the information, Haemodynamic state assessment is really the “bread and butter” of echo information. We will use that information in 90% of clinical situations to change our management. However, it is not enough, because findings of haemodynamically important valve lesions (e.g. severe aortic stenosis) or pericardial effusion will change how we will manage patients. So we struck the dilemma of how much valve assessment we should build into the examination. The problem with echocardiography is that there is such a vast difference in the knowledge base required to perform a limited exam and interpretation versus diagnostic grading of valve lesions using multiple modalities such as 2D, colour flow Doppler and quantitative Doppler. The compromise is to use 2D and colour flow Doppler only, and to grade valve lesions as “OK or “potentially bad”. In the tutorials we will go through what that means, but basically we want you to be able to discriminate a valve lesion that could lead to haemodynamic compromise vs one that does not. We have placed a special tick box in the report to remind you about referring the patient for a follow up comprehensive echo when you identify a problem.

Remember, this scan is to help you manage patients in real time rather than to make you into a diagnostic echocardiographer – if in doubt refer and follow up!

In this regard, we are promoting the concept of limited transthoracic echocardiography to perform Haemodynamic Echocardiographic Assessment in Real Time, or HEARTscan for short. The study should take about 5 minutes once you have practiced it and it can be repeated as often as required without causing any risk to the patient. We believe this may well be an important future development in perioperative management of patients.

We strongly believe, that the entry point to the use of ultrasound in noncardiac anaesthesia, intensive care medicine, and emergency medicine will be performed using surface ultrasound techniques, and as the individual's thirst for knowledge progresses, they may move on to transoesophageal echocardiography and comprehensive echocardiography examinations. This is essentially "round the other way" to what has been done in the last decade. For those wishing to go on and become expert in echocardiography, there are mechanisms available to acquire the knowledge such as the Post Graduate Diploma of Perioperative and Critical Care Echocardiography, which is designed to provide the knowledge base in a systematic manner to become highly competent in echocardiography and surface ultrasound (visit www.heartweb.com.au).

This course is supported by Sonosite, who manufacture small portable echocardiography machines. The same concepts, however, can be performed using conventional ultrasound equipment, (it is simply less portable). It is important that you do not confuse "point of care" with "portable", but you will have the opportunity to evaluate this type of ultrasound equipment which you may not yet have at your institution. This type of equipment does have the advantage of being very robust and relatively drop proof, which is important when you're moving ultrasound equipment from place to place and allowing multiple people to use it. Conventional echocardiography systems are more difficult to drop because they are situated on trolleys, but suffer the disadvantage of being less portable. Ultimately, I envisage that this type of ultrasound equipment will be available as a plug-in module to your conventional monitoring/anaesthetic machines.

This course is therefore designed to provide you with the starting point for ultrasound use, and to give you enough confidence to realise that it is not that hard to do, and to encourage you to start using ultrasound in a limited fashion in your practice. I'm sure you'll soon find that it becomes an invaluable part of your practice and you will be infected with the echocardiography virus!!!

The course is administered through the University of Melbourne. We've chosen the University because it has the extensive infrastructure required to run an educational programme of this nature. The course directors are Colin and Alistair Royse, who head the Human Cardiovascular Research Laboratory in the Cardiovascular Therapeutics Unit, Department of Pharmacology, University of Melbourne. In setting up this course, we have recruited a steering committee comprised of experienced educators in echocardiography within Australia and New Zealand. They include Roman Kluger, Paul Soeding, Michael Veltman, Ajay Kumar, Lenore George, Konstantin Yastrebov and John Farris. We have also asked James Lai from the Auckland City Hospital in New Zealand, and a number of echo gurus from Westmead Hospital including Clement Fong, Alwin Chuan and Chris Ashley to be major contributors to this course either in course preparation or conduct of the hands-on workshops. I am also indebted to Marcelle Wood, the course administrator, and Danielle Nicholas (echocardiography technologist).

Although this has been a group effort, special acknowledgement must go out to our TTE gurus from Perth, Michael Veltman and John Farris, who have really helped evolve our concepts of limited TTE into the HEARTscan format.

This course is divided into two components. The first component you have received in this package, which is the theoretical part of it. It consists of 4 interactive tutorials on DVD, with integration of text and images. It is vital that you study these tutorials and be familiar with the work before you come to the weekend aspect of the course. We will not go over the theory on the weekend, because we want to reserve that for as much hands-on practice as is possible, facilitated by tutors.

The second part of the course is the two days that you come to practice “hands-on”. There are five stands, and delegates are divided into five groups. The idea is that you rotate through each of the five stands in order to cover all aspects of the course. We will start each session with the tutor demonstrating how to perform the echocardiography or ultrasound examination relevant to each stand. We will then rotate the delegates to have hands on practice. Of course we will welcome any questions you have that you may not have understood from the tutorials, but our experience with this type of education in the Post Graduate diploma course is that there is a lot of information in the DVDs, and most people seem to be able to learn that information really well prior to practising the actual technique.

Some of you may have enrolled or completed the Post Graduate Diploma of Perioperative and Critical Care Echocardiography. You'll notice that some of the tutorials are modified from the Post Graduate diploma course. For the others, you will identify the type of teaching that we do in the postgraduate diploma course. The aim of the tutorials, however, are to provide you with extensive knowledge in that area, and the aim over the two days is to practice it in order to give you enough confidence to start doing it yourself in practice. We will essentially overteach in the tutorials and focus on practice in the workshops.