CHEST Original Research

CHEST ULTRASONOGRAPHY

Assessment of Left Ventricular Function

by Intensivists Using Hand-Held
Echocardiography*
Roman Melamed, MD; Mark D. Sprenkle, MD; Valerie K. Ulstad, MD;
Charles A. Herzog, MD; and James W. Leatherman, MD, FCCP

Background: Bedside transthoracic echocardiography (TTE) provides rapid and noninvasive

hemodynamic assessment of critically ill patients but is limited by the immediate availability of
experienced sonographers and cardiologists.
Methods: Forty-four patients in the medical ICU underwent near-simultaneous limited TTE
performed by intensivists with minimal training in echocardiography, and a formal TTE that was
performed by certified sonographers and was interpreted by experienced echocardiographers.
Intensivists, blinded to the patient’s diagnosis and the results of the formal TTE, were asked to
determine whether left ventricular (LV) function was grossly normal or abnormal and to place LV
function into one of the following three categories: 1, normal; 2, mildly to moderately decreased;
and 3, severely decreased.
Results: Using the formal TTE as the “gold standard,” intensivists correctly identified normal LV
function in 22 of 24 cases (92%) and abnormal LV function in 16 of 20 cases (80%). The ␬ statistic
for the agreement between intensivist and echocardiographer for any abnormality in LV function
was 0.72 (95% confidence interval [CI], 0.52 to 0.93; p < 0.001). Intensivists correctly placed LV
function into one of three categories in 36 of 44 cases (82%); in 6 of the 8 cases that were
misclassified, the error involved an overestimation of LV function. The ␬ statistic for agreement
between the intensivist and echocardiographer with regard to placement into one of three
categories of LV function was 0.68 (95% CI, 0.48 to 0.88; p < 0.001).
Conclusions: Intensivists were able to estimate LV function with reasonable accuracy using a
hand-held unit in the ICU, despite having undergone minimal training in image acquisition and
interpretation. (CHEST 2009; 135:1416 –1420)
Abbreviations: ED ⫽ emergency department; LV ⫽ left ventricle, ventricular; TTE ⫽ transthoracic echocardiography

C hemodynamic
ritically ill, hypotensive patients should undergo
assessment as quickly as possible.
Unfortunately, most invasive methods for assessing
*From the Divisions of Pulmonary-Critical Care (Drs. Melamed,
Sprenkle, and Leatherman) and Cardiology (Drs. Ulstad and
Herzog), Hennepin County Medical Center, Minneapolis, MN.
The authors have reported to the ACCP that no significant
conflicts of interest exist with any companies/organizations whose
products or services may be discussed in this article.
Manuscript received October 10, 2008; revision accepted January
13, 2009.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/site/misc/reprints.xhtml).
Correspondence to: James W. Leatherman, MD, FCCP, Division
of Pulmonary and Critical Care, Hennepin County Medical
Center, Minneapolis, MN 55415; e-mail: leath001@umn.edu
DOI: 10.1378/chest.08-2440
hemodynamics involve delays in implementation.
One diagnostic tool that can be used quickly and
noninvasively is limited, point-of-care, bedside trans-
thoracic echocardiography (TTE). Unlike formal
For editorial comment see page 1407
TTE, the limited examination focuses primarily on
exclusion of hemodynamically significant pericardial
effusion and assessment of global left ventricular
(LV) function.1–5 Assessment of LV function is of
particular importance because decreased cardiac
contractility is a common cause of hemodynamic
instability in critically ill patients,6, including those
with sepsis.7,8
The comprehensive TTE has a high sensitivity and
specificity for defining a cardiac cause of shock when

1416 Original Research

performed by experienced sonographers and inter-
preted by cardiologists trained in echocardiography.9
Unfortunately, sonographers and cardiologists are
not always immediately available. Because of this
limitation, limited TTE has become increasingly
used in the emergency department (ED).1– 4 Studies
have shown that emergency medicine physicians can
assess LV function with reasonable accuracy1– 4and
that the focused TTE results in earlier and more
accurate diagnosis.3 Surprisingly, there have been
very few studies5,10 of the use of limited TTE in the
ICU. The current study examined the ability of
intensivists with minimal training in echocardiogra-
phy to accurately assess LV systolic function using a
hand-held unit, with interpretation of a simulta-
neously performed comprehensive TTE by an expe-
rienced echocardiographer the reference standard.
Materials and Methods
Study Population
This study was performed in the medical ICU of Hennepin
County Medical Center, an urban teaching hospital affiliated
with the University of Minnesota. The study population included
44 patients who had a formal TTE ordered by their primary
physician because of one or more of the following indications:
hypotension (n ⫽ 19); dyspnea-hypoxemia (n ⫽ 17); unexplained
tachycardia (n ⫽ 4); increased troponin levels (n ⫽ 3); and ab-
normal ECG (n ⫽ 3).
Training and Interpretation of Focused TTE by Intensivists
Prior to beginning the study, intensivists involved in the study
underwent 2 h of didactic instruction on echocardiography and
4 h of hands-on training by certified ultrasonographers in image
acquisition and visual estimate of the LV function. In addition,
independent study by participating intensivists was encouraged
by providing digitally stored examples of TTEs in which LV
function ranged from normal to severely decreased.
Within 2 h of the formal TTE, patients underwent a focused
bedside TTE by one of four intensivists who used a hand-held
unit (SonoSite 180 [with C15/4-2 mHz MCX transducer];
SonoSite; Bothell, WA). Intensivists were blinded to the results of
the formal study and to the patient’s underlying diagnosis.
Intensivists attempted to acquire images in the parasternal (long
and short axis), apical, and subcostal positions. On the basis of the
limited examination, the intensivists were asked to place LV
function into one of the following three categories: 1, normal; 2,
mild-to-moderate decrease in contractility; and 3, severe de-
crease in contractility.
Comparative Assessment Between Intensivist and Cardiologist
The primary objective of the study was to compare the
intensivist’s assessment of LV function using the limited TTE
with that of an echocardiographer’s assessment of LV function
from the comprehensive TTE. Formal echocardiograms (Sequoia
C 512; Siemens; Malvern, PA) were obtained by certified sonog-
raphers and interpreted by experienced echocardiographers. All
studies performed by intensivists were captured with a videocas-
www.chestjournal.org
Table 1—Normal vs Abnormal LV Function
Formal TTE by Echocardiographer
Limited TTE by Normal Abnormal
Intensivist Findings Findings
Normal findings 22 4
Abnormal findings 2 16
sette recorder attached to the portable ultrasound device for later
review. Whenever there was discordance between the interpre-
tation of the limited TTE by the intensivist and the formal TTE
by the echocardiographer, a different echocardiographer deter-
mined whether the discordance was primarily due to poor image
quality of the limited TTE or to misinterpretation by the
intensivist. Statistical analysis was performed with a statistical
software package (SPSS, version 11.5; SPSS; Chicago, IL). The ␬
statistic was used to allow for comparison in agreement between
intensivist and cardiology interpretation of TTE. The institutional
review board of the hospital approved the study without need for
informed consent.
Results
The 44 patients included 28 men (64%) and 16
women (36%) with a mean (⫾ SD) age of 60 ⫾ 16
years. The most common primary diagnoses were
sepsis (n ⫽ 10), pulmonary edema (n ⫽ 6), pneumo-
nia (n ⫽ 6), and seizure (n ⫽ 5); the remaining 13
patients had other miscellaneous conditions. Eigh-
teen of the 44 patients (41%) were intubated, and 8
patients (18%) required therapy with vasopressors.
The time required to complete the limited TTE was
ⱕ 10 min in most cases.
We first assessed the ability of intensivists to
accurately discriminate normal from abnormal LV
systolic function. Based on the results of the com-
prehensive TTE, there were 24 studies with normal
LV function (category 1) and 20 with abnormal LV
function (categories 2 and 3). Using the comprehen-
sive TTE as the “gold standard,” intensivists correctly
differentiated normal and abnormal LV function on
the basis of the limited TTE in 38 of 44 cases (86%).
Normal LV function was correctly identified in 22 of
24 cases (92%), and abnormal LV function was
identified in 16 of 20 cases (80%) [Table 1]. The
positive predictive value for the intensivists identify-
ing any abnormality in LV function was 89%; the
negative predictive value was 85%. The ␬ statistic for
the agreement between intensivist and echocardiog-
rapher for any abnormality in LV function was 0.72
(95% confidence interval, 0.52 to 0.93; p ⬍ 0.001).
Next, we studied the ability of intensivists to assess
the degree to which LV function was decreased. Of
the 20 studies in which the comprehensive TTE
showed decreased LV function, the degree of abnor-
mality was deemed to be mild to moderate in 13
CHEST / 135 / 6 / JUNE, 2009 1417
 Table 2—LV Function by Category*
Formal TTE by Echocardiographer
Limited TTE by
Intensivist Category 1 Category 2 Category 3
Category 1 22 4 0
Category 2 2 9 2 despite their hemodynamic significance.5 Joseph et
Category 3 0 0 5 al9 found that a comprehensive TTE resulted in a
*Category 1, normal LV function; category 2, mild-to-moderate
decrease in LV function; category 3, severe decrease in LV function.
studies and severe in 7 studies (Table 2). The
intensivist correctly categorized 9 of the 13 patients
(69%) with mild-to-moderate LV dysfunction; LV
function was incorrectly assessed as normal in the
remaining four cases (Table 2). Severe LV dys-
function was correctly recognized by the intensiv-
ists in five of seven cases (71%), with the two
remaining cases misclassified as mild-to-moderate
dysfunction. Overall, intensivists correctly placed
LV function into the appropriate category in 36 of
44 cases (82%); in 6 of the 8 cases that were
misclassified the error involved an overestimation
of LV function (Table 2). The ␬ statistic for
agreement between the intensivist and echocardi-
ographer with regard to placement into one of
three categories of LV function was 0.68 (95%
confidence interval, 0.48 to 0.88; p ⬍ 0.001).
Intensivists often did not obtain good quality
images from all four transducer positions. Nonethe-
less, the cardiologist who reviewed the video record-
ings of the limited TTEs felt that there were only
four instances in which LV function could be as-
sessed with only a low degree of certainty. With a
single exception, when there was discordance be-
tween the intensivist interpretation of the limited
TTE and the comprehensive TTE, the cardiologist
who reviewed the limited TTE tapes sided with the
formal reading rather than the intensivist. This indi-
cated that the most common source of error was
misinterpretation on the part of the intensivist rather
than inadequate image quality.
Discussion
The goal of this prospective observational study
was to determine whether intensivists who had un-
dergone brief and focused training in echocardiog-
raphy were able to assess LV function accurately
using a miniaturized ultrasound unit. Using a near-
simultaneous comprehensive TTE as the “gold stan-
dard,” intensivists were able to differentiate normal
and abnormal LV function correctly in 86% of cases;
in 82% of cases the intensivists correctly classified
LV function as normal, mildly to moderately im-
1418
paired, or severely impaired. When mistakes were
made, intensivists most often overestimated LV
function.
Cardiac abnormalities are common in critically ill
patients and may be unsuspected on clinical grounds
change of management in 51% of patients who were
in shock. Similarly, Kaul et al11 found that a formal
TTE had a high level of agreement with the pulmo-
nary artery catheter findings in patients with hemo-
dynamic compromise and provided complementary
information in cases with discordance. Unfortu-
nately, a formal TTE with cardiologist interpretation
is not always readily available in the ICU. Our study
suggested that minimally trained intensivists using a
hand-held unit can make a reasonably accurate
assessment of LV function in the ICU setting, de-
spite the potential challenges of performing optimal
TTE in the ICU because of factors such as lung
hyperinflation, anasarca, dressings or tubes, and
inability to position the patient optimally.
Surprisingly, few studies have specifically exam-
ined the ability of minimally trained intensivists to
assess LV function in the ICU. Using the interpre-
tation of expert cardiologists as the “gold standard,”
Manasia et al5 found that surgical intensivists cor-
rectly interpreted 84% of limited TTEs, and this new
information changed management in 37% of cases.
Similarly, Vignon and associates10 found that resi-
dents with minimal training accurately differentiated
normal and abnormal LV function in 88% of patients
in a mixed medical-surgical ICU, with interpretation
by intensivists experienced in TTE serving as the
reference. Our study design was slightly different
from these two studies in that we examined medical
ICU patients exclusively and compared intensivist
interpretation of the limited TTE with the results of
a formal TTE interpreted by an experienced echo-
cardiographer, but we found a similar degree of
accuracy in assessment of LV function. These three
studies strongly suggest that minimally trained inten-
sivists using hand-held ultrasound can reliably assess
LV function in the great majority of cases.
Limited TTE performed by noncardiologists has
also been shown to be reasonably accurate in set-
tings other than the ICU.1–5,12–14 In an ED study3
of 184 patients presenting with nontraumatic hypo-
tension, limited bedside TTE resulted in an im-
provement in diagnostic accuracy. In a study similar
to ours, Moore et al1 demonstrated that ED physi-
cians with limited echocardiographic training were
able to estimate LV function accurately in 50 hypo-
tensive patients. The ␬ statistic for agreement be-
tween ED physicians and cardiologists for normal,
moderately depressed, or severely depressed LV
Original Research
function was 0.61; the ␬ statistic for agreement
between two different cardiologists who examined a
random sample of 20 cases was 0.70.1 The latter
finding indicates that disagreement regarding assess-
ment of LV function between experienced echocardio-
graphers is not uncommon.
Even though there are obvious benefits to intensivist-
performed limited TTE in the ICU, the misinterpre-
tation of studies could lead to potentially serious
errors in clinical decision making. For example,
inotropic therapy might be withheld from patients
with hemodynamic impairment resulting from de-
creased LV function if the TTE was misinterpreted
as normal. Conversely, a patient with normal LV
function whose hypotension was due to hypovolemia
or vasodilation might be inappropriately treated with
an inotrope if LV function was incorrectly deemed to
be abnormal. In the present study, the most common
error was failure to recognize a decrease in LV
function rather than misinterpreting normal LV
function as abnormal. It should also be recognized
that limited TTE, as performed by minimally trained
individuals, could fail to identify other important
cardiac causes of hemodynamic compromise such as
cor pulmonale, acute valvular abnormalities, and
intracardiac shunts.11 Indeed, noncardiologists with
minimal training often fail to identify important
cardiac abnormalities such as valvular disease and
regional wall abnormalities.14
Our study was limited to the evaluation of LV
systolic function, but sometimes other information
provided by TTE may be even more important in
managing hemodynamically unstable patients. As
previously mentioned, TTE is an excellent tool to
diagnose acute cor pulmonale and severe valvular
insufficiency. In addition, respiratory variation in
inferior vena cava diameter may help predict the
likelihood of fluid responsiveness, and measurement
of flow across the aortic valve can be used to estimate
cardiac output and calculate systemic vascular resis-
tance.15,16 Future studies should examine the ability
of intensivists to gain proficiency in these additional
uses of TTE.
The present study has several important limita-
tions. First, we studied a relatively small number of
patients and examined the performance of only a few
intensivists. Second, although none of the intensivists
had had any formal training in TTE before the study,
all had had some prior exposure to formal TTEs
during their clinical practice. Third, only a limited
number of imaging planes were used in some cases,
and we did not evaluate the comparative utility of
different transducer positions. Finally, we did not
assess the benefit of the administration of a contrast
agent, which has been shown17 to improve image
acquisition by novice sonographers.
www.chestjournal.org
In conclusion, medical intensivists with minimal
training in TTE obtained adequate images with hand-
held ultrasound units and accurately differentiated
normal and abnormal LV systolic function in the
great majority of cases. Intensivists were somewhat
less accurate in differentiating mild-to-moderate LV
dysfunction from severe LV dysfunction, but severe
LV dysfunction was never misclassified as normal.
When errors occurred, they tended to involve the
overestimation of LV function. Although these pre-
liminary data support the use of intensivist-performed
TTE in the ICU, they also suggest that the optimal
use of this noninvasive tool in the ICU may require
a more rigorous training program, the components of
which include initial training in image acquisition by
skilled ultrasonographers, extensive hands-on expe-
rience with focused TTE, and ongoing feedback
from experienced echocardiographers to improve the
intensivist’s accuracy of interpretation.
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Original Research