Download Modern organization of an echocardiographic laboratory: the

European Heart Journal Supplements (2014) 16 (Supplement B), B89–B91
The Heart of the Matter
doi:10.1093/eurheartj/suu014
Modern organization of an echocardiographic
laboratory: the experience of the King Abdulaziz
Cardiac Center (KACC) in Riyadh
Tahlil A. Warsame1, Mohammad Al Ghamdi1,2, and Ahmad S. Omran1*
1
Non-invasive Cardiac Laboratory, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO BOX 22490, Riyadh 11426, Kingdom of Saudi Arabia
2
King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
KEYWORDS
Echocardiography
laboratory;
Transoesophageal
echocardiography;
Clinical strength;
3D echocardiography
Today, echocardiography is a key diagnostic procedure in clinical and interventional cardiology with expanding indications and applications. It is based on a number of established and rapidly evolving techniques, which make cardiac ultrasound a complex and
very specialized activity. High-volume and high-level echocardiographic laboratories
are performing standard and advanced transthoracic, transoesophageal and stressecho procedures as well as intraoperative and emergency examinations. These modalities require a high level of organization in order to guarantee adequate standards in
terms of appropriateness, accuracy, reproducibility, timing and safety of all procedures,
as well as in terms of education and research activity. We describe the organization of the
Adult Echocardiography Laboratory at the King Abdulaziz Cardiac Center (KACC) in
Riyadh, one of the greatest centers in Saudi Arabia.
Introduction
The Non-invasive Cardiac Laboratory at KACC provides a
wide range of diagnostic services. The laboratory consists
of three main units: Adult Echocardiography Laboratory,
Stress Holter Laboratory, and electrocardiogram (ECG)
Laboratory. Services provided by the Non-invasive Cardiac
Laboratory include adult echocardiography, stress echocardiography, transoesophageal echocardiography, treadmill test, ambulatory blood pressure monitoring, Holter
monitoring, ECG, etc. The number of investigations done
in the Non-invasive Cardiac Laboratory has constantly
increased over the past several years. There are approximately 17 000 adult echo procedures, over 94 000 resting
ECGs, and more than 4500 treadmill stress, Holter and
event monitor procedures performed per year.
The Non-invasive Cardiac Department is staffed with
a multidisciplinary group of over 75 professionals. They
* Corresponding author. Tel: +966 10118011111, Ext. 16205, Fax: 252
0088, Email: [email protected]
include cardiologists, registered nurses, echo technologists,
stress Holter technicians, ECG technicians, and unit
assistants. They are available 24 h a day for emergency care.
The echo laboratory
The Adult Echocardiography Laboratory was established in
May 2001. The laboratory performs both outpatient and inpatient adult echocardiograms utilizing state-of–the-art
equipment. Services provided by the KACC Echo Laboratory
include adult echocardiography, stress echocardiography,
and transoesophageal echocardiography.
The KACC Adult Echo Laboratory is one of the first in Saudi
Arabia to be accredited by the European Association of
Cardiovascular Imaging (EACVI) in 2014. The mentioned
accreditation status signifies that the KACC Adult Echo
Laboratory has met the standards of an independent
review agency that evaluates the quality of critical
elements of the echo process including interpretive and
technical abilities of the sonographers and physicians
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014.
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working in the laboratory and diagnostic accuracy of the
examinations.
Strengths
(1) Clinical strengths
† Diagnosis and treatment of coronary artery
disease, hypertensive heart disease, valvular
heart disease, cardiomyopathy, and adult congenital heart disease utilizing highly advanced echo
imaging techniques.
† Specialized laboratory for real-time three-dimensional
(3D) transoesophageal echocardiography (RT3D-TEE)
before, during, and after the cardiac surgery and/or
cardiac intervention in the catheterization laboratory.
(2) Technical expertise
† 3D Echocardiography: One technology that sets the
laboratory apart is the expertise with 3D echocardiography, an advanced technique that allows doctors
to see the heart in three dimensions—just as a
surgeon would see it. The expertise of the staff in
3D echocardiography and its application to invasive
and structural heart disease keeps the laboratory
on the cutting edge of applied and academic cardiovascular ultrasound.
† Real-time 3D transoesophageal echocardiography:
TEE is used to evaluate the internal heart structures.
Transoesophageal echocardiography is also used
during heart surgeries to evaluate the effects of surgical intervention on the heart, such as the repair of
adult congenital heart disease.
† Echo-guided procedures in the catheterization laboratory: Echocardiography helps in guiding a vast
number of procedures such as catheter-based percutaneous device closure of patent foramen ovale,
atrial septal defect, and ventricular septal defect.
Percutaneous mitral commissurotomy, percutaneous mitral valve repair using the MitraClip system,
transcatheter aortic valve implantation (TAVI), and
echocardiography-guided pericardiocentesis are
also performed.
Organization and metrics
(1) Medical and technical staff
Echocardiography quality is subjective, therefore
dependent on the training level and ongoing experience and education of the medical and technical
staff. KACC Adult Echo Laboratory echocardiologists
are all certified by the Saudi Council of Medicine, and
more than half of them are also certified by the
EACVI. The head of the laboratory is certified
by EACVI and the American National Board of Echocardiography (ANBE). The manager of the Non-invasive
Cardiac Laboratory is certified by the American Registered Diagnostic Medical Sonography (ARDMS) and
the Cardiovascular Credentialing International (CCI).
Two-thirds of cardiac sonographers are registered
through CCI and a majority of those echo technicians
who do not have certification are currently pursuing
the European Association of Cardiovascular Imaging
Certification. The laboratory also has highly trained
T.A. Warsame et al.
and registered cardiovascular nurses who provide
care during conscious sedation and stress procedures.
(2) Equipment
A wide range of ‘state-of-the-art’ products ensure
our staff has access to emerging technologies and wellrounded training.
Achievements
† Accreditation of the EACVI in February 2014 for transthoracic and transoesophageal modalities.
† Eight hundred intraoperative (pre and post) 3D TEE and
650 RT3D-TEE performed.
† More than 100 strain echocardiography for pre, post, and
follow-up chemotherapy patients were performed to
detect early signs of cardiac toxicity. Strain imaging is
now routinely used in the laboratory for chemotherapy
and myocarditis patients.
† The laboratory has assisted 45 TAVI and 13 mitral valve
clip procedures. These new, sophisticated, less-invasive
therapies require highly trained echo cardiologists and
specialized cardiac centers to be performed.
† The Adult Echo Laboratory participated actively in more
than 10 local and international echo conferences and
teaching activities. The KACC Echo Laboratory maintains
strong ongoing ties with several other echo laboratories
within Saudi Arabia and the Middle East region.
Educational activities
† The KACC Echo Laboratory has been a reference center
for most of the 3D echocardiography programs in the
Kingdom. The lab provides extensive training and mentoring for many cardiac centers in the Kingdom.
† For 14 years, the laboratory has been providing to its
medical staff (fellows and cardiac sonographers) for 2
h/week echo review sessions.
† The laboratory also has a 1-year training of post cardiology echo fellowship program which currently has two
fellows enrolled.
† In addition, there is a 2-year post bachelorette training
program for cardiovascular technology under the supervision of the King Saud bin Abdulaziz University for
Health Sciences, which has already produced more
than 12 graduates.
Future plans
† Establishment of an Echo Core Laboratory: to support
clinical and basic science research studies. The Core
Laboratory will offer:
(1) Consultation to investigators that wish to consider
cardiac ultrasound imaging in their study design.
(2) Central echocardiogram reading for clinical trials,
with data stored, analysed, and interpreted.
(3) Calculation of ventricular function with wall motion
scoring, ventricular size, and ventricular mass.
(4) Standard Doppler of blood flow, tissue Doppler,
Doppler-based strain/strain rate, and 2D (speckle)
strain/torsion.
Modern organization of an echocardiographic laboratory
(5) Real-time 3D and 3D electrocardiographic gated
cardiac imaging with quantification of global and
segmental left ventricular function.
(6) Ultrasound contrast studies, including saline contrast
for identification of intra- or extra-cardiac shunting
and transpulmonary contrast agents for left ventricular opacification and myocardial perfusion imaging.
(7) A flexible range of services, from assistance in acquiring high-quality echocardiography images to a
complete service that includes protocol design,
image acquisition, and analysis.
(8) A plan for supporting minimum two sonographers per
year to sit for accreditation exam in adult transthoracic echocardiography administered by EACVI.
† Fellowship program: To expand our current ongoing subspecialty post-cardiology echocardiography fellowship
program under the Saudi Council of Health Specialist.
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Ongoing research projects
(1) Short- and long-term outcomes of mitral valve repair in
the King Abdul Aziz Cardiac Center in the period
between 2003 and 2013 (echo data).
(2) Prediction of outcome of mitral valve repair in ischaemic mitral regurgitation using strain imaging.
(3) Assessment of left ventricular function by strain
imaging pre- and post-aortic valve replacement (TAVI
and surgical replacement).
(4) Comparison of the outcome of mitral valve clip
and surgical mitral valve repair in functional mitral
regurgitation.
Conflict of interest: none declared.