Commentary

Echocardiography: The Good, the Bad, and the Ugly

Are Modern-Day Echo Interpretations a Violation of Conscience?

Melissa Walton-Shirley, MD

Disclosures

November 05, 2018

A critique should be done with sensitivity, serving the higher purposes of improvement in performance and delivery of a better product. Performance of echocardiography and the translation and reporting of its results are long overdue for a critique. The decline is multifactorial. The RVU-driven rush of contemporary medicine leaves little time for explanation.

Sometimes there is a lack of basic understanding of echo findings. Occasionally the personnel assigned the task of reporting the results to the patient are not medically trained. Poor-quality color flow Doppler from multimodality instruments can give the appearance of a bomb detonating in the left atrium, leading to an under- or overestimation of valvular regurgitation. Technical issues with the loading of images from offsite facilities can sabotage any hope of a well-estimated ejection fraction. Then there are reports with very little information: no mention of measurements such as the left atrial dimension, no description of wall motion or wall thickness. In other words, we have work to do in the world of echocardiography.

Three Patient Cases

A 78-year-old patient with chronic obstructive pulmonary disease underwent echocardiography that showed a normal left ventricular ejection fraction (LVEF), mild tricuspid regurgitation, mild pulmonary artery systolic hypertension, and the same mildly abnormal diastolic parameters that a prior echo had shown. He was referred back to his cardiologist urgently because of "heart failure." After generous reassurance, a complete re-examination, and a full explanation of the test results, he went on his way, having wasted 20 minutes of his life and whatever reimbursement a 99214 billing code will suck from the Medicare till. Someone clicked on the diagnosis of diastolic dysfunction in their electronic health record that generated the "heart failure" nomenclature and the urgent office visit.

A 60-year-old woman insisted on being seen emergently as a new patient because of "valve leak." Her husband and daughter accompanied her for support during the discussion of her LVEF of 60% and mild mitral regurgitation. The physician was both diplomatic and reassuring when explaining that "most adult humans have mild valve leak." She was grateful but also crestfallen that she had rung the alarm bell for family members in two states because a secretary at her primary provider's office who called her with the results told her that she'd "better see a cardiologist and soon."

A 40-year-old woman in her eighth month of pregnancy with her fourth child was referred for shortness of air on exertion. Her LVEF was reported at 25% by echocardiogram, and she was immediately sent to the high-risk specialist. After the referral request was put into play, her echo was re-reviewed, and this time the LVEF was reported as greater than 60%. The initial images required a minute to load and play properly; this fooled the interpreter into thinking the patient had a poor ejection fraction, triggering an unnecessary referral and a week's worth of extreme anxiety.

The Father of Echocardiography Is Concerned

By phone, I spoke with Harvey Feigenbaum, MD, who founded the American Society of Echocardiography about the global issue of poor echo performance and the reporting and translation of results.

"I just learned there were 34 million echoes performed last year, and when I think about the quality, it scares the hell out of me," he began. "I feel somewhat like Dr Frankenstein. Maybe I've created a monster," he added, alluding to the burgeoning industry. He equated echo interpretation to throwing a pass in football. You can complete it (correct diagnosis) and help manage the patient, or you may get an incomplete pass from inadequate information or, worse still, the wrong diagnosis. "We cannot afford wrong information," he emphasized.

Feigenbaum makes certain his fellows and sonographers go through quarterly reviews and testing. All of his third-year fellows, regardless of their area of focus, take and pass the echo boards. "I insist that obstetricians and dermatologists need to know what an echo looks like, too" he said. He has also worked with his son to develop online programs to test and teach echocardiography.

When I told him about the patient who was sent back for a "heart failure" diagnosis with no evidence of decline, Feigenbaum warned that "the left ventricular systolic ejection fraction is one of the most overrated concepts out there," and he noted that diastolic or systolic heart failure cannot be diagnosed on echo alone "because we don't treat measurements, we treat patients." When I mentioned the issues with multimodality echo machines, he recommended a dedicated cardiology instrument. He is also very much against a one-vendor laboratory but recognizes that we are often fighting against hospital administrators who find it easier to deal with a single vendor and are willing to sacrifice quality for cost savings.

Should all echo labs be accredited? Feigenbaum's answer was "probably," but he pressed for more rigorous training and better reproducibility. "Echocardiography when done right is fantastic, but if you get it wrong, it's a disaster."

Do Unto Others 

I spent the majority of my career in the cath lab, but the importance of understanding the basic implications of cardiac ultrasonography has never been lost on me. I mourn the lack of recommendations or a concise summary on many of these reports that can make them incredibly difficult for a nonexpert  to understand.  Over the years, I have benefited from radiologists who have added the “consider” or “can’t exclude”  malignancy findings to their reports or recommendations for further imaging. I always try to pay that consideration forward when I interpret an echocardiogram.

Cardiac ultrasonography holds the key to some of the most important prognosticators in all of cardiology. We are morally obligated to interpret studies to the best of our capability,  but we should also translate the findings in  such a way that others can understand what we’ve seen so they may then provide reassurance,  change medical recommendations, or perform adequate surveillance.  After all, the hearts we are studying are loved by someone. They deserve careful measurements and adequate time for assessment and explanation. Anything short of that is a violation of conscience.

Author's note: Some details of these patient cases have been changed to protect their identity. 

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