Established methods to determine asynchrony suffer from high intra- and interobserver variability and failed to improve patient selection for cardiac resynchronization therapy (CRT). Thus, there is a need for easy and robust approaches to reliably assess cardiac asynchrony.We performed echocardiography in 100 healthy subjects and 33 patients with left bundle branch block (LBBB). To detect intraventricular asynchrony, we combined two established methods, i.e., tissue synchronization imaging (TSI) and tissue Doppler imaging (TDI). The time intervals from the onset of aortic valve opening (AVO) to the peak systolic velocity (S') were measured separately in six basal segments in the apical four-, two-, and three-chamber view. Color-coded TSI served as an intrinsic plausibility control and helped to identify the correct S' measuring point in the TDI curves. Next, we identified the segment with the shortest AVO-S' interval. Since this segment most likely represents vital and intact myocardium it served as a reference for other segments. Segments were considered asynchronous when the delay between the segment in question and the reference segment was above the upper limit of normal delays derived from the control population. Intra- and interobserver variability were 7.0% and 7.7%, respectively.Our results suggest that combination of TDI and TSI with intrinsic plausibility control improves intra- and interobserver variability and allows easy and reliable assessment of cardiac asynchrony. In 85 patients, this parameter predicted reverse LV remodeling after cardiac resynchronization therapy (CRT) with a sensitivity and specificity of 92% [et al. identified Ts-SD-12 to be an effective independent predictor of reverse remodeling with a sensitivity of 96% and a specificity of 78% [In a significant percentage of patients with chronic heart failure (CHF), left ventricular (LV) dysfunction is accompanied by conduction disorders such as left bundle branch block (LBBB) . This fry of 92% . Anothery of 78% ,5. Howevy of 78% . As thisIn order to both improve and simplify echocardiographic assessment of asynchrony, we sought to address the problem of intra- and interobserver variability by combination of two established echocardiographic methods - tissue Doppler imaging (TDI)  and tissWe performed echocardiography in 100 healthy subjects and 33 patients with left bundle branch block  using a Vivid 7 ultrasound system . LBBB patients were examined by echocardiography in our center for symptoms of heart failure or as a follow-up after myocardial infarction. Table As a first step, we determined the onset of the aortic valve opening (AVO) as a temporal reference point for all subsequent measurements by pulsed wave Doppler in the five-chamber view. Secondly, we performed TSI (triggered by the AVO) in the four-, two- and three-chamber views. TSI automatically color-codes time-to-peak tissue Doppler velocities, with colors ranging from green  through yellow and orange to red  Figure . Since TUsing the AVO-S' intervals, we calculated the delays  between all analyzed segments in the control population Table . The uppTo detect asynchronous regions, we first identified the segment with the shortest AVO-S' interval. As this segment most likely represents vital and intact myocardium it served as a reference for other segments. We then calculated the delays between all other segments and this reference segment. Segments were considered asynchronous when the delay between the segment in question and the reference segment was above the upper limit of normal delays derived from the control population.For the analysis of intra- and interobserver variability, ten randomly chosen healthy subjects were reexamined by the original and a second investigator. Variability was analyzed by calculation of adjusted coefficients of variation (CV) defined as the ratio of the standard deviation (of the differences between the repeated measurements) and the mean of the absolute AVO-S' values.p < 0.05 was regarded as significant. Receiver operating characteristic (ROC) curves were calculated using SPSS 17.0 .Statistical significance was calculated by Mann-Whitney Rank Sum and z-tests when appropriate . An error probability of The delays between all analyzed segments were markedly longer in LBBB patients as compared to the healthy controls Table . The preAll segments averaged, intra- and interobserver variability was 7.0% and 7.7%, respectively  therapy aims at reverse remodeling and improvement of hemodynamics by amelioration of asynchronous LV contraction. Since all tested echocardiographic parameters failed to reliably predict a positive response to CRT in the PROSPECT trial, echocardiographic assessment of cardiac asynchrony has no evidence-based role in patient selection for CRT and, accordingly, is not recommended by current guidelines . While dIn our opinion, a major problem of the parameters analyzed by the PROSPECT trial lies in their high intra- and interobserver variability which makes them too inaccurate for the clinical routine. Thus, the aim of our study was to establish a new, more reliable and straightforward protocol to determine intraventricular asynchrony based on two established methods. Indeed, reexamination of a part of our study population revealed that combination of both TSI and TDI reduced the intra- and interobserver variability to 7.0% and 7.7%, respectively  which on average was considerably lower in LBBB patients. However, the upper limits of normal that were used to determine asynchronous segments were derived entirely from our control population - independent from our patient group. Thus, their validity may be tested in follow-up studies which include other patient populations, e.g., patients with normal LVEF and LBBB or patients with reduced LVEF in the absence of conduction disorders.Our study is further limited by the lack of data on CRT patients. Based on the encouraging results of this pilot study, however, we are currently applying our approach in CRT patients.Moreover, our approach appears to be oversensitive as all LBBB patients had at least one asynchronous segment. On the other hand, this suggests that our approach would not deny treatment to LBBB patients eligible for CRT according to current guidelines. It may, however, help to improve response to CRT by guiding LV lead placement and by identifying patients with mechanical asynchrony and narrow QRS complexes.In summary, our approach to assess cardiac asynchrony aims at a practical combination of the advantages of TDI and TSI thereby eliminating possible sources of error. By examining 100 healthy subjects we were able to define upper limits of normal delays between all basal segments examinable from apical. Using these standard values we identified a prevalence of asynchronous segments in 33 LBBB patients which is comparable to numbers given in previous studies ,16. Due Further experience in CRT patients will be necessary to evaluate whether our approach helps to improve assessment of cardiac asynchrony in the clinical routine. In addition to improving patient selection for CRT, our method might also be useful in the VV delay optimization.AVO: aortic valve opening; CHF: chronic heart failure; CRT: cardiac synchronization therapy; CV: coefficient of variation; LBBB: left bundle branch block; LV: left ventricle; LVEF: left ventricular ejection fraction; ROC: receiver operating characteristic; S': peak systolic velocity; SD: standard deviation; TDI: tissue Doppler imaging; TSI: tissue synchronization imaging.The authors declare that they have no competing interests.CM designed the study and performed the examinations. HD analyzed the data, performed the calculations and statistical analysis and wrote the manuscript. ACB analyzed and interpreted the data and critically revised the manuscript. SS reexamined control subjects to determine the interobserver variability. BI, BS and GB helped to analyze and interpret the data.All authors have read and approved the final manuscript.Sample 1. Sample clip of TSI and TDI measurements in a control patient without asynchrony.Click here for fileSample 2. Sample clip of TSI and TDI measurements in an LBBB patient with a reduced acoustic window and septal and inferior asynchrony.Click here for file


Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS  ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described.Obtaining competence in ICU echocardiography may be achieved in different ways – either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level – obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs. The application of echocardiography in the critically ill has been well-recognized for several years, principally in patients following cardiac surgery -6. The u) is a scientific society committed to the development of high-quality ultrasound in the emergency and ICU setting, including echocardiography. This document has been prepared from recommendations published by the Royal College of Radiologists . Education of cardiologists in echocardiography is generally achieved as part of a standard training scheme with supervised, hands-on experience combined with attendance at existing national and international courses. Similarly, cardiothoracic anaesthetists wishing to become accredited in TEE will generally spend time in a cardiothoracic centre undertaking a specific fellowship, together with attendance at appropriate courses – some directed specifically towards examination preparation . The maiTraining in echocardiography encompasses both theoretical and practical elements. Theoretical background is prerequisite for the performance and interpretation of an echocardiographic exam   the trainee may wish to practise independently  whilst undergoing training in other areas. It is important to note, however, that accreditation in ICU echocardiography should be to the same standard as other types of echocardiography – completion of any one or all of the modules would not, therefore, equate to accreditation. The principles and requirements for the different levels of training are as follows:• A modular approach to acquiring echocardiographic skills (Appendix 4) under supervision (blended learning)• As different trainees acquire skills at different rates, the end-point of each part of the training programme will be judged by an assessment of practical competence i.e. competency-based assessment• Examinations should encompass the full range of pathological conditions listed in the syllabuses• A logbook listing the number and type of examinations undertaken by the trainee themselves should be kept• An illustrated logbook of specific normal and abnormal findings may be appropriate• Training should usually be supervised by at least a Level 2 practitioner• This would usually require at least 1 year of experience at Level 1, with the equivalent of at least one session per week• A significant further number of examinations should have been undertaken in order to encompass the full range of conditions and procedures encountered in each module• A logbook listing the numbers and types of examinations undertaken by the trainee should be maintained• An illustrated logbook of specific normal and abnormal findings will be presented• Supervision of training should be undertaken by someone who has achieved at least Level 2 competence and has had at least 2 years' experience at that Level• On completion of Level 2 training, the ICU echocardiographer would normally be expected to obtain ICU echocardiography accreditation (section 6.3.2)• This would require practitioners to spend a significant part of their time undertaking echocardiographic examinations, teaching, research and development• They would have spent a continuous period of sub-specialist training in which ICU echocardiography will have been a significant component• They would be able to perform specialised examinations at the leading edge of echocardiographic practice such as the use of intravascular ultrasound contrast agents and the performance of advanced ultrasound-guided invasive proceduresThe log-book should be composed of:• a set of copies of signed reports enclosed in a folder or binder• all reports submitted will carry the signature of the trainee & supervisor• the main sections will include studies performed:- Peri cardiac arrest- Focused studies for haemodynamic measurement- Focused studies for specific diagnosis- Comprehensive diagnostic studies• the studies should include focused and comprehensive assessment of more than one example of each of the following:- Tamponade- Cardiogenic shock- Hypovolemia and Volume responsiveness- Chest trauma- Pulmonary embolism- Septic shock- Acute pulmonary edemaAccreditation in ICU echocardiography should be under the auspices of the appropriate regulatory national and international bodies, and must not represent a substandard or simplified accreditation. Indeed, many would argue that due to the rapidly changing pathophysiology of the critically ill patient, ICU accreditation  should be regarded an upgrade or extension of existing accreditation. In practice, the most appropriate process would be for the existing accrediting authorities  to modify existing examination and logbook content to reflect the clincal situation and casemix of the critically ill. Indeed, similar collaboration between ACTA and the EAE, and ACT and the BSE resulted in TEE accreditation being widely available.Not all practitioners will wish to or need to undergo echo accreditation, however, where required, accreditation must be equivalent to existing echocardiography accreditation programmes, and ideally be run under the direction of the appropriate organisations. Thus:• The accreditation process will be run as a regulatory certificate of competence• In each country, the accreditation should be developed in accordance with national cardiological, echocardiographic and intensive care societies • The accreditation process is designed to teach and test competence at performing, interpreting and reporting studies to the appropriate level. For TEE studies, probe insertion will not be tested, however, interpretation of TTE and TEE images will be required as the two procedures are complementary on the ICU• Each candidate for accreditation must enroll with a suitably qualified supervisor who undertakes to train and supervise (Appendix 3) and to arrange visits to other centres if there are difficulties obtaining an adequate case-mix locally• The accreditation process should require that the candidate submit a log-book and pass a written examination• Applications for approval as supervisor will be invited. Either one or two supervisors at each centre will be approved based on demonstration of competence at echocardiography and evidence of continuing practice• Accreditation is a minimum standard and cannot be regarded as a guarantee of continuing competence. Successful candidates will be expected to begin a process of continuing medical education towards re-accreditation .• The re-accreditation process will include evidence of continuing clinical activity, distance learning and attendance at courses and conferences.and TEE (examination) however, the logbook may contain studies of either TTE, TEE or TTE & TEE, depending on the practice of the applicant. In addition, where the applicant already holds current accreditation in either TEE or TTE, the number of required studies will be reduced accordingly . Where appropriate, studies performed during Level 1 training may be used. In order to allow flexibility for applicants without access to both modalities of echocardiography, accreditation will be based on interpretation of TTE • The log-book will be a set of copies of signed reports enclosed in a folder or binder• All reports submitted must carry the signature of the candidate.• Where intra-operative TEE studies are performed before and after bypass during the same operation, these count as one study. A study performed for the same patient on another occasion counts as a separate study.• The studies should include comprehensive assessment of more than one example of each of the following:- Tamponade- Cardiogenic shock- Hypovolemia and assessment of volume responsiveness- Chest trauma- Pulmonary embolism- Septic shock- Acute pulmonary edema• A letter from the supervisor must be submitted with the completed log-book certifying that the studies have been recorded by the candidate.• The number of exams required to maintain competency is more than 50 and preferably more than 100 examinations per annum ,59• CME/CPD should be undertaken which incorporates elements of ICU echocardiography practice• Regular audit of the individual's echocardiographic practice should be undertaken to demonstrate that the indications, performance and diagnostic quality of the service are all satisfactoryICU echocardiography should be set up as part of the hospital's comprehensive service. Thus, standards of an accredited centre will apply with respect to staff, organisation and equipment , to guarCritical care is delivered on the principle of respect for patients' dignity and cultural backgrounds. Invasive procedures should be fully explained to the patient and undertaken only after consent is obtained. An example of such a procedure is TEE. Exceptions are usually allowed in the case of life threatening emergency and/or where the patient is unable to give informed consent, but this may vary between countries. Where a patient is able to give consent, development of procedure specific consent (PSC) and patient/relative information leaflets (particularly for TEE) may be useful. Where possible, consent should be obtained before images are used by the practitioner for training other practitioners in accordance with local guidelines. Where research is undertaken, ethical approval must be obtained, and consent (for acquisition and use of both TTE and TEE images) sought according to the research protocol agreed and local guidelines.With respect to undertaking TTE, the practitioner will obtain training in the following aspects of patient safety:• Indications and potential pitfalls in interpretation of TTE• Limitations of some minaturised devices with basic configuration • Infection control- Knowledge of local and national guidelines regarding infection control• Electrical hazards• Care of the probe• Probe manipulationWith respect to undertaking TEE, the practitioner will obtain training in the following aspects of patient safety:• Potential complications and their avoidance- Indications, relative and absolute contra-indications for TEE- Anatomy and physiology of the esophagus- Diseases of the esophagus- Endoscopy skills – observation of 50 intubations and > 50 successful supervised intubations- Contraindications of performing procedure – absolute and relative- Patient assessment before, during and post-procedure- Knowledge and understanding of the pharmacology of drugs used in TEE- Knowledge and understanding of the process of obtaining informed consent• Informed consent – see section 6.1• Infection control- Knowledge of local and national guidelines regarding infection control- Knowledge of local and national guidelines regarding probe sterilisation, cleaning and tracking• Electrical hazards• Care of the probe- Procedures for checking integrity of the probe prior to each use- Infection control (see above)• Probe manipulationThe permanent recording of images, where appropriate, is essential for the purposes of correlative imaging, future comparison and audit. A study should be performed and stored on video/digital format to be available for review and comparison. Digital storage is preferred, as it more easily facilitates serial comparison of studies which is invaluable in the management of the critically ill .A system for recording the results of any echocardiographic examination in the patients' record is mandatory . ContentA system for reviewing echocardiographic examinations and their reports within the ICU and in conjunction with the echocardiography department of the hospital is important. Regular audit of the number, quality of studies and their reports should be performed. Responsibility for continuous quality improvement is shared between the trainee and his/her supervisors.An expectation of level 2 and 3 practice is the performance of research in ICU echocardiography. As with all research in the ICU setting, obtaining consent to participate in research is challenging. Whether undertaking research using TTE or TEE, ethical approval and consent must be obtained according to local and/or national guidelines.To a large extent, intensive care has developed in parallel, but separate from cardiology, with little use of the range of physiological measurements and assessments that echocardiography has to offer. This is unsurprising, given the different training pathways that have been followed by intensivists and cardiologists. Indeed, echocardiography has been regarded as the province of the cardiologist since its inception nearly 50 years ago. With increased sub-specialization in the cardiological field, and the development of acute cardiac care as a specific sub-specialty, it is likely that some cardiologists of the future will extend their role into the cardiac ICU setting.The intensivist is, however, uniquely positioned to understand and balance the multi-system pathophysiological variables that underpin critical illness – both in the cardiac and general ICU setting. It is entirely appropriate therefore that intensivists should be able to develop echocardiographic skills, but consequently it is crucial that they should be able to obtain the necessary echocardiographic training such that they are able to practice this physiological investigation to a high level within their intensive care units. Not all intensivists will wish to (or need to) obtain this higher level training in echocardiography, however, every intensivist undergoing training should be competent in peri-resuscitation echocardiography. Where intensivists do wish to develop their echocardiographic skills, their goal should be a recognised accreditation through an established national or international body. This is achievable through collaboration between the existing accrediting authorities and the relevant national and international intensive care socieities – in a manner analogous to that in which TEE accreditation for anaesthetists was developed. The process by which training is obtained remains a challenge, however, the combination of practical training under supervision with interactive on-line learning will facilitate this process where there is no opportunity for an ICU echocardiography fellowship. As with TEE training for cardiac anaesthetists, it is important that this accreditation should be regarded as an entry level requirement for those who wish to develop echocardiographic skills relevant to the ICU setting. ICU echocardiography should not be practiced in isolation, but in conjunction with consultant (echo)cardiologists as part of a comprehensive echocardiography service. In this way, one would hope to see the performance of high quality, relevant echocardiography, together with well-devised and executed research in this rapidly expanding field.With regard to the manuscript "Echocardiography practice, training and accreditation in the intensive care: strawman document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS)", the authors declare not to have any financial or non financial competing interest.SP conceived and wrote the substantial part of the manuscript and of the Appendices. GV gave a major contribution in writing manuscript and the Appendices. DT contributed to the Appendices and to manuscript revision. ES, RB, FG, EC all contributed to manuscript critical revision. All authors read and approved the final manuscript.SP: MB BS BSc MRCP EDICM PhD, Consultant Cardiologist and Intensivist, Adult Intensive Care Unit, Royal Brompton Hospital, London, UK – Acute Cardiac Care Working Group – European Society of Cardiology (Nucleus Group Member) – British Society of Echocardiography Working Group on Intensive Care Ultrasound (Nucleus Member) – Intensive Care Society (UK) Education and Training Committee – WINFOCUS Echo-ICU Group (Member)GV: MD, Intensivist, Anesthesiologist – Dept. of Anesthesia and Intensive Care – Fondazione IRCCS Policlinico San Matteo, Pavia, Italy – WINFOCUS Echo-ICU Group, (Secretary) – Faculty of the WINFOCUS UltraSound Critical Management Course (USCMC) – Director of the SMART Echocardiography for Intensivists CourseES: Consultant, MD, PhD, DMSc – Dept. of Anaesthesiology and Intensive Care at Aarhus University Hospital, Skejby, Denmark – EACTA Echo Committee, member – WINFOCUS Echo-ICU Group (Member) – Member of WINFOCUS Directory BoardRB: MD, Scientific Employee at Hospital of the Johann Wolfgang Goethe-University, Frankfurt am Main, Germany – Consultant Anesthetist and Internist, EDIC – Main Scientific activity: Ultrasound research and development for Anesthesia and Critical Care Medicine – WINFOCUS Echo-ICU Group (Member) – Member of WINFOCUS Scientific CommitteeEC: MD, Cardiologist, Anesthesiologist – Unit of Anesthesia and Intensive Care, "A. De Gasperis" Cardiologic Department – Niguarda Cà Granda Hospital, Milan, Italy – Faculty of the WINFOCUS UltraSound Critical Management Course (USCMC) – WINFOCUS Echo-ICU Group (Member).mailto:bilotta@tiscali.itFG: MD, Director of Cardiothoracic Anaesthesia Dept. and ICU, Azienda Ospedaliera Universitaria Pisana – President of ITACTA, Italian Association of CardioThoracic Anaesthesiologists  – EACTA Echo Committee, member – WINFOCUS Echo-ICU Group (Member)DT: MD MPH, Director of Critical Care Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center – Associate Professor of Anesthesia, Harvard Medical School Boston, MA, USA. – WINFOCUS Echo-ICU Group, (Chair) – Member of WINFOCUS Directory BoardThis basic theoretical training is a prerequisite to any practical training in echocardiography.• The basic components of an ultrasound system• Types of transducer and the production of ultrasound, with an emphasis on operator controlled variables• Use of ultrasound controls• An understanding of the frequencies used in medical ultrasound and the effect on image quality and penetration• The interaction of ultrasound with tissue including biological effects• The basic principles of real time and Doppler ultrasound including colour flow and power Doppler• The recognition and explanation of common artefacts• The safety of ultrasound and of ultrasound contrast agents• Image recording systems • Choice of echocardiographic modality (TEE vs. TTE)• Choice of machine • Patient information and preparation• Indications for examinations• Relevance of ultrasound to other imaging modalities• The influence of ultrasound results on the need for other imaging• Scanning techniques including the use of spectral Doppler and colour Doppler• Image recording• Image storing and filing• Reporting• Medico-legal aspects – outlining the responsibility to practise within specific levels of competence and the requirements for training• Consent• The value and role of departmental protocols• The resource implications of ultrasound useAppendix 3).The minimum dataset required for completion of a comprehensive TTE study is shown below. In all cases, recording of patient demographics is mandatory. Unless peri-resuscitation, and ECG recording is not readily available, this should always be applied. Where focused echocardiography is used, only part of the "minimum dataset" for a comprehensive exam is required, and this is described in detail in Appendix 5. Where TTE images are non-diagnostic, TOE may be indicated - mitral leaflet tips- papillary muscles• Apical four chamber• Apical five chamber• Apical two chamber• Apical long axis• Subcostal views to show the right ventricle, atrial septum and inferior vena cava• Suprasternal view4. M-mode or 2D measurements• LV dimensions from the parasternal long axis or short axis view- Septal thickness at end diastole- Cavity size at end diastole- Posterior wall thickness at end diastole- Cavity size at end systole- Aortic root dimension- Left atrial dimension5. Color Doppler mapping• For the pulmonary valve in at least one imaging plane• For all other valves in at least two imaging planes6. Quantitative spectral Doppler• Pulsed Doppler at the tip of the mitral leaflets in the apical 4-chamber view. Note E and A velocities, and E deceleration time• Pulsed Doppler in the left ventricular outflow tract. Note systolic velocity integral• Continuous wave Doppler across the aortic valve in the apical 5-chamber view. Note the peak velocity• Continuous wave Doppler across the tricuspid valve. Note peak velocity.• Pulsed or continuous wave Doppler in the pulmonary artery7. Tissue Doppler imaging• TDI  of annular motion in the apical 4-chamber view. Basal free wall, septal, and RV.Table 2 [see additional file Appendix 5.The minimum dataset required for completion of a comprehensive TEE study is shown below. In all cases, recording of patient demographics is mandatory. Unless peri-resuscitation, and ECG recording is not readily available, this should always be applied. Where focused echocardiography is used, only part of the "minimum dataset" for a comprehensive exam is required, and this is described in detail in 1. Identifying information• Patient name• A second unique identifier such as CRN or date of birth• Identification of the operator e.g. Initials2. An ECG should be attached3. 2D views• Transgastric LV short axis• Transgastric LV long axis• Transgastric LVOT• Transgastric RV long axis• Deep transgastric• Mid-esophageal four chamber• Mid-esophageal bicommissural• Mid-esophageal long axis• Aortic valve short axis• RV inflow/outflow• SVC/IVC• Pulmonary veins• Pulmonary artery bifurcation• Descending/arch/ascending aorta4. M-mode or 2D measurements• LV dimensions from the transgastric short axis view- Cavity size at end diastole- Cavity size at end systole• Aortic root dimension• Left atrial/mitral annulus dimension• Right atrial dimension5. Color Doppler mapping• For the pulmonary valve in at least one imaging plane• For all other valves in at least two imaging planes6. Quantitative spectral Doppler• Pulsed Doppler at the tip of the mitral leaflets in the mid-esophageal long axis view. Note E and A velocities, and E deceleration time• Pulsed Doppler in the left ventricular outflow tract. Note systolic velocity integral• Continuous wave Doppler across the aortic valve in trans-gastric LVOT view/deep transgastric view. Note the peak velocity• Continuous wave Doppler across the tricuspid valve. Note peak velocity.• Pulsed and continuous wave Doppler in the pulmonary arteryTable 3 [see additional file Appendix 5.Although training in ICU echocardiography is divided into levels of competence, as already described [Additional file Appendix 1):The entry level modules for echocardiography will include focused TTE in the peri-arrest situation, aimed to make a diagnosis from a limited differential (FEEL ). An add• Principles of US• Principles of Doppler• "Knobology"• Pitfalls and artefacts• Patient safety and consent• Sono-anatomy of the heart• Focused Echocardiographic Evaluation in Life support (FEEL)• Focused Assessment with Transthoracic Echocardiography (FATE)• Qualitative evaluation of the left ventricle• Qualitative evaluation of the right ventricle• Measuring IVC &/or SVC diameter• Measurement of LVOT peak velocity and VTI• Measurement of Cardiac Output• Estimation of peak PA pressure• Quantification of LV systolic function• Quantification of RV systolic function• LV diastolic function• RV diastolic function• Estimation of left atrial pressure• Detection of myocardial ischaemia• The Aortic valve-AS/AR• The Mitral valve-MS/MR• The Tricuspid valve• The Pulmonary valveThere are conditions that occur in the ICU that require addressing specifically in a document concerned with ICU echocardiographic training which may be the subject of focused or comprehensive examinations. These include:• Assessment of shock• Hypovolemia, volume responsiveness and filling status• Tamponade and pericardial disease• The sepsis syndromes• Effects of pre-load and afterload• Hypoxemia• Anatomical shunt• Acute Cor Pulmonale • Complications of acute MI• Echo in chest trauma• Weaning failure from mechanical ventilation• Hemodynamic measurementsAppendix 5.Where a study performed is focused, rather than comprehensive, this should be stated in the report. The specific details regarding the basic echocardiographic modules for focused assessment in each of these clinical scenarios are addressed in • Practical training should involve carrying out regular echocardiography examinations in the critical care unit or echo department, with approximately 5 examinations performed by the trainee (under supervision) per week• A minimum number of examinations should be undertaken – 50–100 is deemed as appropriate number of examinations required for a trainee to become competent. However different trainees will acquire the necessary skills at different rates and the end point of the training programme should be judged by an assessment of competencies.Appendix 5• Examinations should encompass the full range of pathological conditions and practical procedures listed in • A logbook listing the types of examinations undertaken should be kept• Training should be supervised either by someone who has obtained at least Level 2 competence in critical care echocardiography themselves• Trainees should attend an appropriate theoretical course and should be familiar with the published literature• During the course of training the competency assessment should be completed as this will determine in which area or areas the trainee can practise independently, i.e focused echocardiography in resuscitation• Practical training should include at least 1 year of experience at Level 1 with a minimum of one session or equivalent per week• A logbook listing all examinations undertaken should be kept• A level 2 practitioner should have the competencies to undertake a recognised accreditation• The trainee should be part of a departmental continuous quality improvement program• Supervision of training should be undertaken by someone who has achieved at least Level 2 competence in critical care echocardiography, has had at least 2 years' experience at that level and would normally be of consultant status• A Level 2 practitioner will be able to accept referral from Level 1 practitioners• A level 2 trainee should be involved in echocardiographic research with the aim of advancing the knowledge base of the fieldThe critical care echocardiographer must take great care in the interpretation of ventricular function. It must be taken in the context of the clinical status of the patient, and the level and degree of inotropic support. Hence, the normal range values that apply in the outpatient setting may not be relevant to the ICU.Myocardial damage causing left and/or right ventricular systolic dysfunction can result from a number of pathologies seen on the ICU including:• Acute coronary syndromes• Septic myocardial depression• Acute myocarditis of other etiologiesOther conditions can cause systolic ventricular dysfunction, without necessarily causing myocardial damage i.e. excessively increased afterload to the right ventricle resulting in decreased systolic performance. When assessing ventricular function, each ventricle should be considered alone, and also in conjunction with the other ventricle.LV systolic function can be evaluated using echocardiography (TTE and TEE) in many ways; however, each has its limitations:• Shortening fraction by M-mode examination – only assesses basal systolic function and is load dependent• Fractional area change (FAC) – subject to geometric assumptions and is load dependent• Ejection fraction (EF) – subject to geometric assumptions and is load dependent• Tei index – is also load and ventricular activation dependent ,71• Long axis function and tissue Doppler Imaging (TDI) – may assist  in the assessment of LV systolic function ,73RV systolic function can also be evaluated using echocardiography, and should not be overlooked in the critically ill:Tricuspid annular plane excursion during systole  obtained by M – mode or TDI of the tricuspid annulus is well validated in assessment of RV systolic function. Problems with correct alignment using TEE may be overcome using anatomical M-mode Regional myocardial function plays an important role in diagnosis of myocardial ischemia – a new regional wall motion abnormality suggesting the onset of new ischemia. Regional wall motion abnormalities are detected using various echocardiographic tools, including:• 2D assessment with wall motion scoring indices• Long axis annular motion and the demonstration of post-ejection shortening• Tissue Doppler and myocardial strain (for the experienced echocardiographer)Standard assessment is with 2D detection of regional wall motion abnormalities, however, these occur relatively late in the ischemic cascade. Of relevance to the ICU setting, where TTE is used to detect regional wall motion abnormalities, echocardiographic contrast agents improve endocardial border definition and hence diagnostic sensitivity, howeverThere is much debate in the literature regarding the definition of diastolic dysfunction; however, for the purposes of ICU echocardiography, this should be taken to mean abnormalities of ventricular filling that may be independent of systolic dysfunction,77. As aThis can be assessed using TTE and TEE. Necessary for interpretation are:• Trans-mitral Doppler flows (PW)• Pulmonary vein Doppler flows (PW)• Tissue Doppler Imaging (TDI)• Abnormalities in LV filling may occur in many conditions seen in the ICU, including aortic stenosis, hypertension, tamponade, pulmonary embolism, and severe LV systolic dysfunction. Any interpretation of LV filling patterns must therefore be made in the context of the full echocardiographic study.Although less well studied, there are features of right ventricular function that suggest the diagnosis of RV diastolic disease. These include:• Dominant diastolic flow in the SVC or IVC • Presence of a significant A wave on pulmonary arterial Doppler throughout the respiratory cycle • Inappropriate (for age) dominant E wave on trans-tricuspid fillingThe finding of diastolic filling abnormalities (right and/or left-sided) in the critically ill patient should signal caution in the interpretation of filling pressures measured by standard invasive means, as such patients may require relatively high filling pressures to maintain cardiac output. Where very short trans-mitral filling patterns are seen:• The filling pattern may be summation at high heart rates• If E wave filling only, a high heart rate may be needed to maintain cardiac output• If A wave filling only (particularly where dominant E wave filling is expected) a reason for suppression of early diastolic filling should be sought• If pacemaker programming is changed to optimize filling in restrictive disease, the echo should be repeated to ensure ventricular filling has not been further compromisedInadequate circulating volume is a common feature of many of the syndromes encountered in ICU and optiEchocardiography enables assessment of the patient's volume status which is complementary to, and may be more reliable than measurements performed by traditional invasive hemodynamic monitoring -85. In tIn the ICU setting, the following considerations must be taken into account:• Assessment of VR requires measurement of multiple parameters• LV or RV end-diastolic dimensions are unreliable predictors of VR• The effects of Intermittent Positive Pressure Ventilation (vs. spontaneous ventilation) must be considered when looking at changes due to respiration• Preload responsiveness Indices have been validated mainly in septic shock and perioperative patients• Where a patient is not in sinus rhythm or is ventilated with intermittent spontaneous respiratory activity, assessment of VR by means of heart-lung interactions study may not be accurate. Here, assessment of the effect of passive leg raising may be the right tool -89• Non echocardiographic VR heart-lung interaction-based indices (such as Pulse Pressure variations) may present false positives  which can be easily detected by echocardiography.The following parameters have been suggested to indicate severe hypovolemia in the critically ill, and should be measured routinely when assessing for volume responsiveness using echocardiography:• Small hyperkinetic LV , with cavity end-systolic obliteration   • Signs of systemic venous congestion (dilated fixed-diameter IVC and SVC) in the absence of tamponade• High estimated LV filling pressures – but note caution with restrictive ventricular disease (section 5.1.2)In fully mechanically ventilated patients in sinus rhythm, predictors of VR are:• Superior Vena Cava Collapsibility Index > 36%• Inferior Vena Cava Distensibility Index > 18% or 12%9• LV Ejection variations: LVOT Vmax Variations > 12%, LVOT VTIn spontaneous/assisted ventilation, or in case of rhythm other than sinus, passive leg raising can be used as an endogenous fluid challenge to assess VR : an incrThis can be done by means of:• Cardiac Output measurement (at LVOT or at AV orifice) ,102 – an• LVEDA – increase will parallel the reached increase in LV preload and with maintained systolic function, lead to an increase in stroke volume ,103,104• Doppler estimations of LV filling pressures (section 5.2.2) – to determine tolerance to the fluid challengeNote: raised pericardial pressure and/or pleural pressure may lead to physiological "underfilling" of the ventricle(s) demonstrated using echocardiography, even when pressures measured by standard invasive means are increased. In assessment of filling, it is the trans-myocardial pressures that matter, not the absolute values measured.The pericardium comprises two layers , with 5–10 ml pericardial fluid between the layers, and serves to restrain the four cardiac chambers within a fixed volume. There are a number of conditions where inflammation and/or accumulation of fluid in the pericardial space may cause abnormal hemodynamics on the ICU include:• trauma• cardiac surgery• congestive cardiac failure• myocardial infarction• inflammatory/infective pericarditisMost inflammatory conditions affect both layers, and may be associated with the accumulation of fluid in the pericardial space, in addition to the development of pericardial constriction.The pericardium and pericardial space should be assessed in all views using TTE where possible. Following cardiac surgery, or where images are sub-optimal, a TEE may be indicated (see below). Of note:• The thickness of the pericardium and depth of any pericardial fluid should be measured (TEE thickness > 3 mm 95% sensitive & 86% specific) • The presence of any loculations should be noted. In particular, where percutaneous drainage is being considered, subxyphoid views should be obtained and suitability for drainage assessed• Left ventricular function should be assessed – particularly with respect to motion of the posterior and septal walls (PLAX)• Using M-mode on the PLAX or RVOT view, RV diastolic collapse may be demonstrated where there is tamponade• Doppler examination of the following should be performed in all cases, in particular noting variation with respiration:- trans-mitral and trans-tricuspid- trans-pulmonary- LVOT• Finally, the diameter of the SVC should be measured, together with variation with respiration, and the venous return to the right heart recorded using PW DopplerThe commonest pericardial disease seen in the ICU is tamponade. Here, the degree of hemodynamics compromise caused by accumulation of pericardial fluid is related to the intra-pericardial pressure, which in turn will depend upon both the volume and rate of accumulation Features of tamponade may not be typical in the ICU :• Phasic changes in flow with inspiration and expiration are reversed in positive pressure ventilation)• The presence of classical echocardiographic changes depend upon a global collection with equal transmission of increased intrapericardial pressures. Under certain circumstances , these • Following cardiac surgery, not only are these features often absent  but coll• Tamponade can also occur in the absence of a pericardial collection, such as with large pleural effusions .This is an unusual indication for ICU echo. Where a patient has elevated right heart filling pressures, resistant to diuresis and a history suggestive  the diagnosis may be suspected. The physiological changes result from fusion of the pericardial layers forming a sac of restricted capacity. Thus, there is interdependence of filling of the LV and RV, which occurs in early diastole. Clinical features include:• Elevated JVP which rises on inspiration (reversed with IPPV)• Peripheral edema/ascites• Pulsus paradoxus (may not be present)Characteristic echo findings include thickened pericardium, preservation of ventricular long-axis function (TDI), marked respiratory variation in trans-valvular Doppler velocities, and dominant × descent on SVC/IVC venous filling . Where aEchocardiography can play a key role in the management of the septic ICU patient both by excluding cardiac causes for sepsis, and by guiding haemodynamic management of those patients in whom sepsis reaches such a severity to jeopardize cardiovascular function and survival.Sepsis and septic shock (SS) are the most common causes of ICU mortality ,113. SS Each echocardiographic assessment should seek for the following situations, thus guiding fluid therapy and inotropic/vasoconstrictor support institution and titration:Due to peripheral flow distributive derangements, normal values of cardiac index (CI) should not be considered necessarily adequate in SS. However, determination of CI can provide the following information:• An indicative value to class the patient into ranges of CI • A reference for subsequent determinations after therapeutic intervention or clinical changesA state that can be easily and thoroughly assessed (section 5.2). Echocardiographic assessment of a patient in the initial phase of SS will generally reveal hypovolemia with hyperkinetic biventricular systolic function, unless underlying chronic cardiac dysfunction, other sepsis-triggered cardiac derangements co-exist, or aggressive mechanical ventilation (hindering RV function in the context of ARDS/pneumonia) is used. Where the shock state is volume-resuscitated, echocardiography can be used to determine VR  biventricular systolic function.• Always screen for pre-existing cardiac dysfunction• Where ventricular dysfunction is found in a patient with SS, an ECG may help to distinguish between acute coronary syndrome-determined dysfunction (triggered by sepsis) from true sepsis-related myocardial dysfunction. Cardiac troponins may not .• LV dysfunction can be masked by sepsis-associated vasodilatation and preload inadequacy: always reassess LV function after preload and afterload optimization.• Assessment of LV (and RV) systolic function should be performed after correction of hypovolemia.• Extreme tachycardia (or tachyarrhythmia) can make volume status and bi-ventricular function difficult to assess. Here, assessment of the vena cavae may be helpful. Re-assessment after sinus rhythm/acceptable heart rate restoration will give more reliable estimate of myocardial dysfunction, if present, and outline a different volume status situation.Infective endocarditis (IE) is a microbial infection of intracardiac structures facing the blood. It can be encountered in ICU patients both as cause of admission or as acquired infection leading to a septic state with no evident focus.The diagnosis of IE is defined on the basis of a well established set of diagnostic criteria of which echocardiography is one of the major ,132. IE • Three echocardiographic findings are important in establishing diagnosis of IE:- Mobile echo dense mass(es) attached to valvular or mural endocardium, or to implanted material- fistulae or abscess formation- new disruption or dehiscence of a prosthetic valve • TEE has greater sensitivity for detection small vegetations and on mitral valve IE than TTE. Both techniques reach high specificity in equal manner.• The clinical context influences the diagnostic capability of TTE and TEE: while with low IE pre-test probability a negative good-quality TTE can exclude the diagnosis, TEE should be performed on all TTE negative cases with a high index of clinical suspicion. In mechanical ventilated ICU patients TEE is almost invariably needed .• TEE is mandatory in the assessment of suspected prosthetic valves IE, and in TTE positive cases to identify major valvular complications and guide surgical planning .This is uncommon – probably due to the lack of the hemodynamic factors usually associate with the pathogenesis of IE  , however• Clinical presentation of IE in the acutely ill can be highly variable• Echocardiography alone cannot be used to make diagnosis of endocarditis: a combination of clinical-instrumental-microbiological criteria is required• A third to a half of IE develops in absence of pre-existing cardiac pathology or prosthetic devices• Keep high suspicion for endocarditis in ICU bacteremic patients with unknown septic focus, especially if patients with prosthetic valves, implantable devices, or known significant native valve pathology• In severely damaged native valves , clear identification of small vegetations may be very difficult. Differential diagnosis between prosthetic valve IE and non-obstructive thrombus, or between bioprosthetic valve IE and degeneration, can be very challenging• Viewing of vegetations on implantable devices (mass or sleeve-like) may be difficult, due to artefacts coming from the device itself. Small fibrin strands may represent a difficult differential diagnosisAll indices of LV/RV systolic and diastolic function currently used in clinical practice are heavily load dependent: findings must always be interpreted in the context of drugs/situations affecting afterload • Assessment of a low cardiac-output state contributing to arterial hypoxemiaIn addition, transthoracic lung ultrasound may be helpful, but is beyond the scope of his document.Echocardiographic demonstration (TTE or TEE) of a cardiac cause for pulmonary edema ultimately relies on detection of pulmonary venous hypertension and its underlying cause ,148, by:- LAP estimation (see section 5.12.2)- Assessment of LV function- Assessment of left-sided valvular pathologyWhere the LAP is high and venae cavae suggest adequate filling, in the absence of any relevant cardiac pathology, simple volume overload may be diagnosed.• TTE assessment is usually adequate to make the diagnosis• If a TEE is indicated, the hypoxemic patient will probably require intubation• The cause of pulmonary edema may be dynamic and/or occur on ventilatory weaning . Here, a focused/targeted echocardiographic study (or stress echo) should be considered at the time of deterioration (see section 5.11)• Isolated diastolic dysfunctionis extremely rare as a cause of acute pulmonary edema in ICU ,150• Multiple causes of hypoxemia may coexist• Unilateral pulmonary edema mimicking pneumonia has been described as consequence of eccentric mitral regurgitation ,152intracardiac shunt  [Intrapulmonary shunt, unaffected by such hemodynamic factors, has been described in thoracic trauma, liver cirrosis [Hypoxemia unexplained by pulmonary clinical-radiological findings may be due to intra-cardiac or intra-pulmonary shunting (or both). In ICU many factors increasing right sided intracavitary pressures can trigger or exacerbate the effects of such condition in case of mponade) -158. Intcirrosis . The chocirrosis ,161. The- a positive agitated saline contrast study: microbubbles passage into left atrium, either immediate  or delayed  - direct visualization of PFO, ASD- color-Doppler demonstration of right to left flow through PFO, ASD• Provocative maneuvers  may be required to exclude PFO• A high LAP may mask an intracardiac shunt • A significant right to left shunt may lead to overestimation of non-echocardiographic CO measurementsAcute cor pulmonale is a life threatening condition characterized by a sudden severe increase of right ventricular afterload, determining a hindrance to RV ejection. Major causes of acute cor pulmonale are represented in ICU by acute pulmonary embolism and mechanical ventilation during ARDS.Massive pulmonary embolism (PE) is a cause of Acute Cor Pulmonale (ACP) encountered in ICU. Only direct visualization of thrombi in the pulmonary arteries enables a definitive diagnosis ,165, how- pulmonary hypertension at CW Doppler on tricuspid regurgitation- signs of RV systolic overload - signs of diastolic overload: (RV enlargement: RVEDA/LVEDA > 0.6)- RV free wall hypokinesia- Moderate to severe tricuspid regurgitationBedside echocardiography can nevertheless greatly aid clinical decision making in patients with acute PE  and moni• Differential diagnosis with RV AMI can be made on clinical context, absence of pulmonary hypertension, and coexistence of LV postero-inferior hypokinesia• Gradation of RV dilatation by ventricular diastolic area ratio may be misleading in patients with coexisting dilated cardiomyopathy.• Pre-existing chronic pulmonary hypertension may be suggested by RV hypertrophy, RA dilatation, and systolic pulmonary arterial pressure greater than 60 mmHg ,171Where radiographic appearances suggest acute pulmonary edema, demonstration of normal left-sided filling pressures may suggest the diagnosis of ARDS/ALI . Of noteWhere the diagnosis of ARDS/ALI is made, mechanical ventilation may have unfavorable effects on RV function, due to lower lung compliance and secondary increase in alveolar pressure and pulmonary vascular resistances -175. OuvCoronary artery disease is the commonest acquired heart disease in adults, resulting in a reduction or interruption in coronary flow, with effects on ventricular and valvular function. The major complications relevant to the ICU setting that result from acute MI include acute MR, infarct expansion and ventricular septal rupture, right ventricular infarction, ventricular thrombus, and free wall rupture. Of note, almost all complications of acute myocardial infarction (AMI) may be diagnosed using 2D and color flow echocardiography . The curClass I• Diagnosis of suspected acute ischaemia or infarction not evident by standard means• Measurement of baseline LV function• evaluation of patients with inferior MI and clinical evidence suggesting possible RV infarction• Assessment of mechanical complications and mural thrombus (TEE indicated when TTE studies are not diagnostic)Class IIaIdentification of location/severity of disease in patients with ongoing ischaemiaClass IIIDiagnosis of AMI already evident by standard meansThere is a recognized cascade of echocardiographically detectable abnormalities that occur as a result of myocardial ischaemia which correlate with the degree of flow reduction in the coronary arteries. Many of these occur before the onset of ECG abnormalities and are readily detectable in the ICU setting. This sequence of events is :• Normal ventricular function• Perfusion abnormalities (detected with perfusion contrast agents)• Abnormal long axis function  associated with suppressed early transmitral filling on Doppler)• regional wall motion abnormalities (2D echo)• ECG changesThere is extensive literature regarding regional wall motion abnormality scoring and the relevant coronary artery involvement . Where possible the segmental approach to scoring regional wall motion changes following acute myocardial infarction should be used. Of note, these regional wall motion changes detected using 2D echo occur relatively late in the ischemic cascade. The earlier echo findings of ischaemia (particularly related to long axis function) are particularly useful in the ICU setting, however, there are particular considerations for this patient group, including:• Echo contrast may be contraindicated • Images may be suboptimal for accurate interpretation of TDI – here, M-mode of the mitral/tricuspid annulus is usually achievable• Where there is significant LVH and excessive inotropic support, these echo findings may prove useful as an early indicator of induced ischaemia• The development of these changes post-operatively or on attempting weaning from respiratory support may indicate significant coronary artery disease• TEE may be useful in visualising the first few centimetres of the coronary arteries (particularly post-aortic root surgery) and identifying high velocities associated with restriction of coronary flow.Suspect acute mitral regurgitation (MR) post-AMI with hemodynamics compromise, pulmonary edema and pan-systolic murmur. The etiology of acute MR is readily detected using TTE +/- TEE and may be due to papillary muscle rupture, or LV dysfunction resulting in MV dysfunction. Where a• Partial/complete papillary muscle rupture- Usually postero-medial papillary due to single coronary artery blood supply - Color flow mapping helpful in detecting jet presence and direction - TEE may be necessary to determine anatomy accurately• Infarction of the LV wall with disruption of normal MV coaptation- Often posterior leaflet restriction (posteriorly directed jet)- Jet may be central/eccentric- Regurgitation may be very dynamic, depending upon loading conditions and ongoing ischemiaOf note, in the ICU setting ischemic MR may be difficult to diagnose :• TTE images may be suboptimal, especially if patient ventilated and in pulmonary edema. Here, TEE may be indicated to make the diagnosis• Grading the severity of MR: account must be taken of the pre-load and after-load, and if necessary loading and inotropic conditions altered.• In severe MR the characteristic regurgitant jet recorded on continuous-wave (CW) Doppler may be short and of low velocity (< 3 m/s), and in the most severe cases may not be visualized using colour flow. Here, PW Doppler (showing laminar flow) or ventricular angiography may be necessary.• Ischemic MR is a recognized cause of failure to wean from ventilatory support in the ICU. Where suspected, a targeted echocardiographic study performed when the patient is clinically compromised is indicated. If not possible, stress echocardiography  may be necessary.This is a relatively uncommon complication following the introduction of effective and prompt thrombolysis and/or percutaneous coronary intervention . As with• Does not follow congenital patterns of VSD – may occur at any point along the interventricular septum – non-standard views may be needed• The path of the VSD may be eccentric (or multiple) – first identify the defect using color flow Doppler, and subsequently perform 2D imaging• Apical VSDs may be particularly difficult to identify using TEE• Additional assessment should include: biventricular function and pulmonary arterial pressuresThe index of suspicion of RV infarction should be particularly high in patients with an inferior AMI due to occlusion of the proximal RCA. Echocardiographic features include :• Impairment of RV function (as in LV ischaemia) assessed using M-mode and TDI of the RV LAX – may be relatively subtle• Dilatation and hypokinesis/akinesis of the RV are less common (assess using 2D and M-mode and TDI of the RV LAX) – indicate more extensive infarction• Associated secondary tricuspid regurgitation• Falling PA pressures (from TR) may indicate progressive RV dysfunction• High right-sided pressures may be indicated by right-left shunting through a PFO• LV systolic function usually well-preserved (may see inferior WMA)The pericardial space should be imaged as described in section 5.3. A small amount of fluid in the pericardial space is not uncommon following a trans-mural AMI, and rarely causes hemodynamic compromise. Rupture of the free wall of the left ventricle may occur (rarely since introduction of thrombolysis) and will result in a very rapidly accumulating collection in the pericardial space – and is almost invariably fatal.Echocardiography either TTE or TEE may be performed in the emergency room department to assess the effects of blunt and penetrating chest trauma. The range of findings and echocardiographic indications are beyond the scope of this paper, which focuses specifically on ICU echocardiography. Indications for emergency assessment are widely discussed,61,185 aThere are several considerations in the echocardiography of patients with chest trauma that are admitted to the ICU. First, TTE has a relatively low diagnostic yield compared with TEE. Second,• Hemopericardium – the hemodynamic consequences depend upon the site, rate and volume of collection ,192. Sma• Pleural collections – echocardiography may demonstrate the presence of a pleural collection. Where associated with a pericardial collection, high intra-pleural pressures may be transmitted to the pericardium resulting in tamponade which may be resolved by evacuation of the pleural and pericardial fluid• Aortic valve disruption – any type of disruption of the valve can occur both from penetrating and non-penetrating injury. Acute disruption may result in catastrophic regurgitation. Late ef• Aortic disruption – may occur due to blunt or penetrating chest trauma, or deceleration injuries. TEE has a high sensitivity and specificity for diagnosis of aortic disruption, but note may miss disruption of arch or branches • VSD – often atypical position. Determine with color flow first, then anatomy with 2D• Coronary artery disruption – may see associated evidence of ischemia (section 5.1) and/or fistulae• Mitral valve disruption – penetrating wounds to the chest (knife or bullet) have been associated with MV regurgitation. The anatomical abnormality may be missed using TTE• Myocardial contusion – may see regional wall motion abnormalities, or global dysfunction. Either/both ventricles may be affected, being right ventricular free wall more frequently involved . Note, dWhere concomitant pneumothorax exists, TTE may be unhelpful and TEE required, however, beware polytrauma – where there is esophageal, maxillofacial or cervical spine injury, TEE is contra-indicated and other imaging modalities should be used. In each case, a comprehensive study should be performed, with attention to both anatomical and physiological assessment. Finally, where the hemodynamic status changes, echocardiographic studies should be repeated if the diagnosis is unclear, and may be used to guide volume replacement (section 5.2).Shock is a global state of inadequate tissue oxygenation, is seen commonly on the ICU, and may be cardiogenic, hypovolemic, distributive, obstructive or dissociative (or any combination of the above). The use of focused ultrasound in many shock states is well-recognized ; however• Tamponade• Cardiogenic shock• Hypovolemia• Massive pulmonary embolism• Tension pneumothoraxAs with all echocardiographic examinations, a comprehensive study should be performed where time allows, however, where time does not permit, the following more focused study may be considered:• Is there pericardial fluid? – lf present, look for signs of tamponade, but note exceptions to the rule (section 5.3)• Is the heart hypokinetic? – if so, how bad is the heart (given the level of support) which ventricle(s) is (are) involved, and are filling pressures elevated (section 5.12.2). If ischaemia is suspected, look for regional wall motion abnormalities, and signs and complications of myocardial ischaemia/infarction (section 5.1)• Is the heart hyperkinetic? – if so, is the heart empty or volume overloaded? Look for signs of significant valvular pathology• Is the heart "normokinetic"? – is this appropriate for the clinical state of the patient? Is it in reality relatively hypokinetic?• How well filled is the heart? – assess IVC size in the clinical context and if distended and not collapsing with inspiration, seek potential causes • Where no cardiac indicators are seen, ultrasound of the thorax and abdomen should be consideredWhere a diagnosis is suspected, a more detailed study (as discussed in the preceding sections) should be performed to confirm/refute and refine the diagnosis. This can be oriented by the dominant clinical feature : systemiWeaning from mechanical ventilation fails in about 25% of patients meeting weaning criteria. With di• A change of Doppler indexes toward an increase in left atrial pressure• New/worsened regional wall motion abnormalities• A decrease in LV global function• Appearance/worsening of mitral regurgitationOf note, and similar to the concept of stress-echocardiography, great importance has comparison of findings with a basal exam, to be done immediately before starting the weaning trial.Echocardiography is widely used for the hemodynamic assessment of valvular pathology – regurgitation or stenosis. Valve disease as a primary pathology leading to ICU admission is uncommon. When present, the diagnosis may be challenging to the echocardiographer as the cardiac output may be markedly reduced, or the patient hemodynamically unstable. This is particularly notable when stenosis is suspected in a low cardiac output state, as here, trans-valvular velocities may be low. Careful echocardiographic assessment of all four valves is essential in a comprehensive study, with interpretation of trans-valvular forward and regurgitant velocities being interpreted in the clinical context of the patient.More common is the use of echocardiography for interpretation of hemodynamics in a structurally normal heart. Here, values may be obtained (using TTE or TEE) to estimate left atrial pressure, pulmonary arterial pressure and cardiac output, and guide institution and monitoring of therapeutic interventions ,11. It iDisease of the tricuspid valve leading to ICU admission is extraordinarily rare.• The commonest use of measurement across the TV in the ICU is to assess systolic Pulmonary Artery Pressure (PAPs)• TTE assessment – generally better for hemodynamics than TEE • TEE assessment – used where no TTE views are possible, or detailed imaging of the TV (i.e. to exclude endocarditis) is needed. Standard views include ME4Ch, modified bicaval view, transgastric short and long axis views• Where there is free TR, color Doppler is unreliable, and PW Doppler should be performed• Severe TR may be indicated by a regurgitant jet of short duration and low velocityPulmonary valve disease rarely is an indication for ICU admission – except following cardiac surgery.• TEE is often not helpful in assessment of the PV  and here TTE provides adequate views (PSAX)• Where suspected, PW and CW Doppler should be performed• In severe PR, although color Doppler may be unhelpful, PW Doppler showing regurgitation of short duration  indicates severe PRThis is generally calculated from the peak TR velocity, however• Where there is no TR:- mean pulmonary artery pressure estimated from peak pulmonary artery regurgitant velocity.- peak pulmonary artery systolic pressure from pulmonary acceleration time.• Doppler of the pulmonary valve is dependent upon accurate placement of the cursor at the level of the valve leaflets – or pulmonary hypertension may be overestimated• Falling PAPs may indicate failing RV rather than successful treatment of pulmonary hypertension (here the PAT may be more specific)The commonest cause of valve disease in the Western World is now previous valve replacement. Elsewhere, rheumatic valve disease is still prevalent. Left-sided valvular pathology as a cause of ICU admission is more common than right-sided pathology.Aortic stenosis (AS) is increasingly common in the elderly. The diagnosis is suggested from calcification of the aortic valve and immobile cusps, visible• There are no agreed hemodynamics values for what constitutes significant AS in the critically ill patient• Where LV function is poor and CO low, the measured velocity and thus derived pressure drop across the aortic valve may be correspondingly small. Peak velocity below the valve should be measured by PW Doppler across the LVOT and across valve by CW Doppler. A four-fold step-up in velocity across the aortic valve to be indicative of severe AS.• AS will tend to be under-estimated in the presence of MS • ICU admission can be precipitated in patients with (known and unknown) severe congenital sub-aortic stenosis.Aortic regurgitation (AR) is readily detectable using TTE and CW Doppler, even in• Aortic velocities reach zero before end-diastole• diastolic MR may be seen• flow reversal in the descending aorta should be sought using PW Doppler• M-mode of the mitral valve demonstrates premature closure.Significant mitral stenosis (MS) may mimic ARDS, presenting with poor gas exchange and bilateral pulmonary infiltrates. The history will usually suggest the underlying diagnosis. Even in the ICU, echocardiographic findings are characteristic. A precipitant for acute deterioration may be the onset of atrial fibrillation. Where the patient is admitted to the ICU in extremis, emergent balloon valvotomy or valvuloplasty may be considered. As with aortic stenosis, sequential stenotic lesions and/or a low cardiac output may lead to an underestimation of severity.• Diagnosis of severe MS should be made using standard echocardiographic criteria• Where intervention is considered for cardiogenic shock on the ICU, TEE assessment of the valve is useful to determine suitability for valvotomy or valvuloplasty• In extremis, a small increase in valve orifice area may improve the hemodynamics sufficiently such that the patient may be suitable for subsequent more definitive surgeryMitral regurgitation (MR) severe enough to require ICU admission is likely to be catastrophic, with patients presenting with cardiogenic shock and/or pulmonary edema. MR of this severity may be associated with both typical and atypical echocardiographic features, includi• Hyperdynamic LV (M-mode) – despite low CO state• Reduced end-systolic volumes (2D and M-mode)• Anatomical MV disease (best demonstrated using TEE)• V wave cutoff sign on CW Doppler of MR trace (i.e. of short duration and low velocity)• Color Doppler interrogation may underestimate the severityOf note also, IPPV and drugs used for sedation alter hemodynamics sufficiently to reduce the apparent severity of MR by at least I-II grades. Thus, severe MR may only become apparent on attempting to wean from ventilator support. Where suspected, volume loading and the use of pressor agents should be considered to mimic usual (and stress) hemodynamics. In the case of suspected ischemic MR, other strategies should be employed (section 5.1 and 5.8)The left atrial pressure (LAP) may be estimated using several parameters – although widely used in the out-patient setting, the use of these techniques in the critically ill is currently not extensively validated. They may, however give a useful indication as to the presence of extremely high LAP, or a normal LAP which may be crucial in the diagnosis of many critically ill patients. In addi• MV deceleration time < 120 msec predicts PCWP > 20 mmHg • MV deceleration time > 153 msec predicts PCWP < 23 mmHg• Isovolumic relaxation time = 0 indicates LAP > 30 mmHg• The LAP may be estimated from the MR pressure drop, however, this is less accurate than on the right side of the heart• Increasing E/Ea ratio > 10 indicates LAP > 15 mmHg Cardiac output (CO) may be measured using many echocardiographic techniques,216; howHere, the LV stroke volume is obtained by measuring the CSA of the LVOT multiplied by the trans-aortic VTI. The greatest error is in measuring the LVOT – and TEE views may well be necessary.• TTE: LVOT diameter from PLAX view, Doppler from A4Ch view• TEE: LVOT from MO LAX view, Doppler from TG LAX viewMany echocardiographic measures may be used to estimate pulmonary vascular resistance/high pulmonary arterial pressures,219 incl• A short pulmonary acceleration time (< 70–90 msec) – correlates with a high pulmonary vascular resistance• The ratio of peak tricuspid regurgitant velocity to the RVOT VTI – correlates well if the PVR is > 6.0 Wood Units• The ratio of the RV pre-ejection period to ejection time – increased with an increase in pulmonary artery diastolic pressure, pulmonary vascular resistance and mean pulmonary artery pressure Of note,Echocardiography is not useful in the estimation of systemic vascular resistance, although esophageal Doppler  is widely used as a monitoring device in the ICU to determine cardiac output and SVR.As with any measure of hemodynamics, numbers obtained should be interpreted in the clinical context, and sequential values are generally required. ProlongMinimum dataset and additional data comprising the standard adult TTE study. The table summarizes the minimum and additional data comprising the standard adult TTE study by, view, modality, structure, measurements, and derived calculations.Click here for fileMinimum dataset and additional data comprising the standard adult TEE study. The table summarizes the minimum and additional data comprising the standard adult TEE study by, view, modality, structure, measurements, and derived calculations.Click here for fileProposed Levels of competence for echocardiography in ICU. The picture illustrates the proposed levels of competence for echocardiography in ICU and their relation to the accreditation process and to research and training activities.Click here for fileModular structure of the Echocardiography in ICU training programme. The picture illustrates the modular structure of the Echocardiography in ICU training programme, wich comprises emergency-introductory, basic and intermediate stages, each one with its own modules.Click here for file