Vera H. Rigolin, MD, FASE

I am writing this President’s Message in July. Let me share with you what is going on in my echo lab. New fellows and residents have started. There is a lot of excitement in the air about the new academic year. July is also the month for the National Board of Echocardiography (NBE) examination for adult echo. As a result, there is a flurry of activity among the fellows planning to take the exam for the first time and attending cardiologists planning to recertify. Most of the attendings are walking around shaking their heads thinking, “Has it REALLY been 10 years?!” There are lots of discussions about echo artifacts, PISA calculations, and echo physics. My lab is also preparing for recertification of our accreditation through the Intersocietal Accreditation Commission (IAC). As a result, all of our lab’s protocols are being reviewed, sample studies are being collected from the sonographers and attending physicians, and documentation of all of our QA sessions is being compiled. All of this is a lot of work for everyone. So, why do we do it? Because, quality matters .

Oftentimes we forget the significant impact that our technology has on patient care. Take, for example, a 54-year-old female who presents to her primary care physician for a routine physical exam. The physician hears a loud murmur. The physician is familiar with the Appropriateness Criteria for Echocardiography Document and knows that an initial echo is appropriate when there is reasonable suspicion of valvular or structural heart disease. An echo is then ordered and is performed in the echo lab. The patient spends one hour with the sonographer who carefully performs a complete two-dimensional (2D)/M-mode echo with Doppler examination. The sonographer also recognizes that an accurate assessment of left ventricular ejection fraction is needed, and so acquires three-dimensional (3D) echo images. The left ventricular ejection fraction is calculated to be 50%. How does the sonographer know to do this? First, the sonographer has attended sonography school and has passed the certification examination administered by the American Registry for Diagnostic Medical Sonography (ARDMS), or by Cardiovascular Credentialing International (CCI). The sonographer has also attended all of the quality assurance (QA) sessions in the echo lab mandated by IAC in order to ensure that the images acquired are correct and align with the protocol of the lab. In addition, ASE’s new valvular regurgitation guidelines have been reviewed and discussed in the lab. The patient’s echo is then sent to the physician for interpretation. The physician notes that the mitral valve is myxomatous and there is bileaflet prolapse. The physician notes the large PISA radius measured by the sonographer and confirms that the effective regurgitant orifice area is greater than 0.4 cm ² . The physician notes the holosystolic nature of the jet as well as the systolic flow reversal in the pulmonary veins and concludes that the mitral regurgitation is severe. How does the physician know how to do this? First, the physician has achieved at least level 2 training during his/her cardiology fellowship and has passed the NBE examination. In addition, he/she actively participates in all of the QA sessions recommended by the IAC. He/she has also reviewed the recently updated ASE Valve regurgitation guidelines. The physician then confirms the sonographer’s calculation of the ejection fraction and reports that it is 50%. The physician has read the AHA/ACC guideline for management of patients with valvular heart disease and recognizes that an ejection fraction less than 60% in a patient with severe, organic mitral regurgitation is a class 1 indication for surgery. The echo physician then calls the patient’s referring physician to discuss the case. The patient is then referred for consultation with a cardiologist, followed by a consultation with a surgeon. This scenario is how patient care is “supposed” to happen.

Now, imagine the scenario where the left ventricular ejection fraction was erroneously measured as 65% or the mitral regurgitation was erroneously interpreted as moderate rather than severe. In both cases, a patient with a class 1 indication for surgery would have been deprived of a much-needed surgery. This scenario is how patient care is “not supposed” to happen.

ASE supports all measures to improve quality in echo labs. There are numerous educational products and courses offered by ASE to help sonographers and physicians keep up with basic and novel echo techniques. ASE offers two online publications to help keep abreast of the field. The Journal of the American Society of Echocardiography (JASE) showcases the latest echo-based cardiovascular research. ASE’s newest publication, CASE, illustrates the clinical application of echo through a case-based approach. There are also numerous ASE guideline documents to help sonographers and physicians accurately acquire and interpret echo images. One of ASE’s new initiatives is to publish abridged versions of the documents in order to facilitate the understanding and implementation of the information contained in the guidelines.

ASE supports certification of sonographers and physicians, as well as accreditation for echo laboratories. ASE also endorses the new critical care examination currently being developed by the NBE in collaboration with eight other medical societies. This exam, which will be given to eligible candidates in January 2019, will help drive quality initiatives outside of the traditional echo lab.

The NBE and IAC share ASE’s commitment to quality in echo. It is in concert with these organizations that major strides can be made to improve quality and ultimately impact and improve patient care. NBE and IAC are also strong supporters of the ASE Foundation, which funds research and educational initiatives and supports training grants for novice healthcare workers. Through the collaborative efforts of ASE and all of the accrediting/certifying bodies along with the motivated and caring sonographers and physicians in all of the echo labs around the world, we will continue to strive to do the right thing for all of our patients.