Hand-carried echocardiography for assessment of left ventricular filling and ejection fraction in the surgical intensive care unit

Purpose: To better define the reliability of left ventricular ejection fraction (LVEF) and left ventricular filling, as determined by either hand-carried ultrasound (HCU) or formal transthoracic echocardiography (TTE), in the critically ill surgical patient. Materials and Methods: Prospective cross-sectional study of 80 surgical intensive care unit patients with concomitant (< 30 minutes apart) formal TTE and clinician-performed cardiac HCU. Visual estimates of LVEF and left ventricular filling (underfilled vs normally filled) were recorded, both by clinicians performing HCU and fellowship-trained echocardiographers. Results: Bland-Altman plot analysis of LVEF estimates revealed good interobserver agreement between HCU and formal TTE (% LVEF mean bias, 2.2; with 95% limits of agreement, perpendicular to 22.1). This was similar to agreement between independent echocardiography observers (% LVEF mean bias, 1.3; with 95% limits of agreement, +/- 21.0). However, assessments of left ventricular filling demonstrated only fair to moderate interobserver agreement (kappa = 0.22-0.40). Of note, a greater percentage of the 5 standard acoustic windows were obtainable using formal TTE (72% vs 56%). Conclusions: Formal TTE offers no advantage over HCU for determination of LVEF in critically ill surgical patients, even though the former allows for a more complete examination. However, estimations of left ventricular filling only demonstrate fair to moderate interrater agreement and thus should be interpreted with care when used as markers of volume responsiveness. (C) 2009 Elsevier Inc. All rights reserved.