CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 AFRICA 269 Non-echocardiographers acquiring echocardiographic images need to be trained adequately in acquisition and interpretation to meet consistently high standards. The American Society of Echocardiography (ASE) has published guidelines on focused cardiac ultrasound, including training.34 The ASE recommends that this training include didactic education, hands-on experience and interpretation experience. The aim of this study was to assess the feasibility of a training programme for non-echocardiographers based on the ASE recommendations in resource-limited settings with handheld echocardiographic machines. Methods Echocardiograms were performed on 100 patients, including children and adults, at the Cape Coast Teaching Hospital in Ghana between July and September 2018. The first 100 patients to consent were included, regardless of the reason for presentation to the hospital. Residents were selected for training based on their willingness to participate. The study was approved by the Cape Coast Teaching Hospital ethical review board. All patients who agreed to participate in the study were included. Participants gave appropriate consent and assent where applicable. The Lumify probe (Lumify, Philips, Amsterdam, the Netherlands) is a 1–4-MHz single-phased array cardiac transducer equipped with scanning software that is connected to an Android tablet interface. The transducer performs most of the beam forming, image acquisition and reconstruction processing. The smart device serves as the display screen and is connected to a cloud-based application. The touchscreen display allows users to tap to start functions, pinch and drag to zoom in and out, and swipe to expand the images. Images can also be wirelessly transferred to a picture-archiving and communication system. Two internal medicine residents at the Cape Coast Teaching Hospital in Cape Coast, Ghana were trained. The training consisted of a didactic component, which included instructional videos with a paediatric cardiologist available to answer questions, which was followed by proctored image acquisition, independent imaging, and interpretation of echocardiograms. Echocardiographic training focused on obtaining limited echocardiographic windows for qualitative assessment of left ventricular (LV) size and function, right ventricular (RV) size and function, and presence or absence of pericardial effusion. Colour flow, doppler and evaluation of valvular stenosis and regurgitation were also discussed, but were not the focus of the study and were therefore not included in the evaluation phase. This training model was based on ASE recommendations for focused cardiac imaging with handheld machines.34 The didactic component consisted of training lectures, including basic ultrasound principles, basic cardiac anatomy and physiology, orientation to the machine, and demonstration of scanning, standard scanning windows and steps in interpreting echocardiographic studies (Table 1). During the didactic section, trainees were able to observe imaging by ultrasound technicians. After the didactic and observation period, trainees began a 10-week practical training that included a minimum of 20 individual scans per trainee with interpretations (Table 2). Each scan included multiple grayscale images: two each from the parasternal long-axis, short-axis and apical four-chamber views over a preset two-second loop (Table 3). M-mode images from the parasternal short axis at the level of the papillary muscles and through the aortic root and left atrium were obtained over four beats. These training scans were performed under direct supervision by a third-year paediatric cardiology fellow. Immediate feedback was provided to help improve image quality and understanding for subsequent studies. After the first six-week proctored phase, each trainee performed additional training that included three weeks of proctored imaging and interpretations and a one-week period of independent imaging and interpretation. Trainees reviewed images immediately after scanning and recorded interpretation in a secured REDCap database.35 Interpretation included qualitative analyses of LV and RV structure and function as well as evaluation of pericardial effusion. Each scan was independently interpreted by a paediatric cardiology fellow for comparison. Eachtraineeperformed50echocardiogramsandindependently interpreted 20 randomly selected studies. Evaluations occurred at three predetermined timepoints. The first was following six weeks of proctored training (20 proctored studies performed and 10 interpreted studies per trainee), the second following an additional three weeks of proctored training (20 independent studies performed and five interpreted studies per trainee), and the last at the completion of the study (10 independent studies performed and five interpreted studies per trainee). Statistical analysis All statistics were performed using Stata version 14.2 (StataCorp LP, College Station, TX). Kappa coefficients were calculated to measure inter-rater reliability. Predetermined cut-offs of < 0.00, 0.00–0.20, 0.21–0.40, 0.41–0.60, 0.61–0.80 and 0.81– Table 1. Didactic content Basic principles of ultrasound/echocardiography Handling of portable echocardiogram machine Cardiac anatomy and physiology Imaging windows in echocardiography Subjective assessment of LV structure and function Subjective assessment of RV structure and function Subjective assessment of atrial structure Evaluation of pericardium Table 2. Elements of practical training Two-dimensional imaging Qualitative assessment of LV structure and function Qualitative assessment of RV structure and function Qualitative assessment of atrial structures Presence and severity of pericardial effusion M-mode LV shortening fraction (parasternal short axis) Table 3. Images obtained in protocol Imaging window View Parasternal long axis 2D Parasternal short axis 2D, M-mode Apical 4-chamber 2D
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