Point of Care Ultrasound: Pearls for Heart Failure ManagementSharon L. Mulvagh MD, FRCPC, FACC, FAHA, FASEProfessor of Medicine, Dalhousie University, Halifax, NS, CanadaProfessor Emeritus, Mayo Clinic, Rochester MN, USA

Point of Care Ultrasound: Pearls for Heart Failure ManagementSharon L. Mulvagh MD, FRCPC, FACC, FAHA, FASEProfessor of Medicine, Dalhousie University, Halifax, NS, CanadaProfessor Emeritus, Mayo Clinic, Rochester MN, USA Conflict of Interest Disclosures•Grants/research support:•Consulting fees: LantheusMedical Imaging•Speaker fees: •Other: SteeringCommittee: NovoNordisk(SOUL trial) •I willnot discussoff-label uses OBJECTIVES1)Understand the purpose and basic components of point of care ultrasound (POCUS)2)Describe typical POCUS findings associated with Heart Failure3)Understand the pitfalls of POCUS technology and interpretation4)BONUS: role of POCUS in COVID19 POLL: My exposure to POCUS would be best characterized by which of the following statements:1)I regularly use POCUS in clinical assessments with confidence2)I am occasionally using POCUS, and feel confident in my skills3)I am occasionally using POCUS, but do not feel confident in my skills4)I have limited prior echo experience and am contemplating getting a POCUS device5)I have access to a POCUS device, but have no idea how to use it6)I don’t have access to a POCUS device, but wish I did, and want to learn how to use it7)POCUS? It’s just HOCUS-POCUS. Why do we need it?8)None of the above What is Point-of-Care Ultrasound?•Ultrasonography performed and interpreted by the clinician at the bedside and integrated in to patient care in real time-goal directed workflow-diverse specialties-multi-system interrogation-24/7 availability-repeatable Portability and Miniaturization of Ultrasound Systems THENNOW POCUS Scope 20182014, 2018 2011 2011 Purpose: Expedite care A tale of 2 Cases CASE 1: 69 yofemale, no prior cardiac historynew onset dyspnea NYHA II •Clinical assessment: (hx, physical findings, CXR, BNP)•ED Dx: left heart failure, murmur•Managed w/ IV diuresis; Discharged: furosemide 40 mg od •Out-ptEcho , Cards clinic (3 mos)•BUT: one month later: severe dyspnea; tried increasing furosemide •Returns to ED: rales, murmur; hypokalemia and mild renal dysfunction•Echo-pending. No clinical follow-up has occurred •Admitted for Dx(TTE), Rx 69 year old female with dyspnea –TTE one month after symptom onset TTE: flail mitral leaflet, severe MR, normal EF Case 2: 63 yomale , mild progressive dyspnea, sudden worsening, presyncope •ED: murmur -CV consult -POCUS Case 1 vs Case 2????POCUS made a differencein management & outcome POCUS: flail mitral leaflet, severe MR, normal LV function•Admitted: intraopTEE, MV repair•Back to work within 3 weeks DISRUPTION ©2012 MFMER | 3177424-14©2011 MFMER | 3149421-14 Basic Ultrasound controls (“Knobology”)•Probe selection-lowfrequency: (2-5 MHz): deepstructures: cardiac, abdomen-highfrequency: (8-10 MHz): shallow structures: vascular, lung •2-D controls-depth-overall gain (brightness) •Color Flow Doppler-red: towards-blue: away US penetration is inversely proportional to the frequency Ultrasound Tissue Characteristics•Echogenic structures are white•Bone •Tissue•Air•Echolucentfluid is black•blood•effusions Ultrasound reflection Ultrasound transmission LV size/functionRV size/functionPericardial Effusion IVC -Volume StatusSignificantValvulopathy BasicPoint of Care Echocardiographyfor Heart Failure “ A-lines B-linesLung Exam Basic Exam: Cardiac•Parasternal: Long Axis (PLAX), Short Axis •Apical•Subcostal ©2012 MFMER | 3177424-17 •LV size •LV function•RV size, function•Pericardial fluid?•Ascaorta size•MV, AV Majority of info can be obtained from PLAX, Subcostal PLAX PSAXPLAX Basic Exam: Cardiac•Parasternal: Long Axis (PLAX), Short Axis •Apical•Subcostal ©2012 MFMER | 3177424-18 Majority of info can be obtained from PLAX, Subcostal PLAX IVC –Fluid Volume Estimation•size (< 2.1 cm)•respiratory variation:decreases > 50% with sniff’ 4-chamber view-assess pericardial effusion CHF Basic Exam: Lung Pleural Effusion A-LinesB-Lines Lungs just don’t get in the way!Valuable info in the artifactsobserved Kimura BJ Am J Cardiol2011: 108:586-590 Integration: Cardiopulmonary Limited US Exam (CLUE) in the diagnosis and management of CHFPLAX-LV, RV, valvesSubcostal-IVCLung Normal CHF Clinical Integration: Differentiating the typical symptom of Heart Failure: Dyspnea •CHF•Pericardial Effusion•ValvularHeart Disease•Pneumonia•Pulmonary Embolism•COPD PLAPS PLAX POCUS in the differential diagnosis of Dyspnea•Pulmonary Embolism Pulmonary Embolism Pericardial Effusion Validation & ReliabilityA growing literature indicates that POCUS: •provides more accurate diagnosis than physical exam for majority of common CV abnormalities, including CHF•results in less downstream testing; potentially reducing overall cost for patients being evaluated for a CV diagnosis•predicts mortality outcomes in discharged hospitalized patients •may reduce readmissions in CHF patientsMarbach JA et al. Ann Intern Med. 2019;171:264-272RaziR et al. J Am SocEchocardiogr2011:24:1319-24KobalS et al. Am J Cardiol2005; 96: 1002-1006Mehta M et al. J Am CollCardiolImg2014;7:983–90Wooten J Ultrasound Med 2019; 38:967–973. GaribyanJ UltrasoundMed2018; 37:1641–1648 Gordon, M et al. ACEP Sept, 2019 Wooten J Ultrasound Med 2019; 38:967–973. LUNG US findings:-more accurate than CXR for dx PulmEdema-predict early and late mortality GaribyanJ UltrasoundMed2018; 37:1641–1648 POCUS -Advantages•Real time imaging•Portable•Noninvasive•Widely available•No ionizing radiation•Inexpensive•Extension of physical exam POCUS -Insonation: The Fifth PillarOf the Modern Physical Examination NarulaJ, ChandrashekharY, BraunwaldE. JAMA Cardiol2018 INSONATION INSPECTION PALPATION AUSCULTATION PERCUSSION “It is time to add a fifth pillar to the armamentarium of modern physical examination, insonation, with a miniaturized, portable handheld device.” Limitations•Poor penetration of bone•Poor imaging behind bones or air-filled regions (shadowing)•Mechanical (breakability/power source); Cost•Infection Control; Billing; Archiving•SKILL REQUIRED = TRAINING§acquisition§interpretation§integrationOnline learning and hands-on experience (simulators, patients) Seek proper training! Know your limitations! https://aseuniversity.org/ase/conferences/ Cardiovascular POCUS for the Medical Student and Novel User •Intro: Cardiac POCUS –Views, Correlation to Basic Anatomy•Complete Cardiac POCUS Scan•Integrated Cardiac POCUS and Physical Examination•Pathology •Teaching the Teacher -How and What to Teach Medical Students •Standards and Testing https://aseuniversity.org/ase/lessons/47 Cardiac POCUS: Training and Goals Kirkpatrick JN et al. J Am SocEchocardiogr. 2020; 33:409-22 POCUS: CLOUD-BASED LEARNING & AI•Lumify: REACTS-integrated “tele-ultrasound”•Butterfly: Augmented Reality Telemedicine Technology “Tele-Guidance technology” https://www.youtube.com/watch?v=dlIOTFyKMVUwww.butterflynetwork.comhttps://www.usa.philips.comhttps://www.youtube.com/watch?v=GpJYzfn1J5Y POCUS and COVID19 J Am SocEchocardiogr. 2020; in press Take Home : POCUS and CHF management•POCUS is a disruptive innovation that is here to stay•Newer devices, less cost, interactive guidance•Challenges our conventional CV approaches with potential for added value –immediate results, integrated into patient care•Basic assessment: cardiac, lung, vascular (IVC) •rapid, repeatable•CHF practice: •differential diagnosis of dyspneic patients•serial monitoring, dismissal timing•follow-up, Rx guidance•Requires appropriate training Additional POCUS Online Learning Resources•https://aseuniversity.org/ase/lessons/47•http://www.susme.org/learning-modules•http://www.sonomojo.org/complete-foamed-ultrasound-curriculum/•http://imbus.anwresidency.com/core.html•http://imbus.anwresidency.com/advanced.html•http://pie.med.utoronto.ca/TTE/index.htm•http://pocusjournal.com/•https://sites.google.com/site/calgaryimus/home Thank You! 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