Smith Aisling, Purna Jyothsna R, Castaldo Michael P, Ibarra-Rios Daniel, Giesinger Regan E, Rios Danielle R, Weisz Dany E, Jain Amish, El-Khuffash Afif F, McNamara Patrick J
Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.
Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
Echocardiography. 2019 Jul;36(7):1346-1352. doi: 10.1111/echo.14409. Epub 2019 Jun 27.
Subjective assessment of right ventricular (RV) function by neonatal echocardiography lacks validation. Incorrect diagnostic assignment in patients with suspected pulmonary hypertension (PH) may lead to unnecessary treatment or missed treatment opportunities.
Six evaluators (experts [n = 3], novice [n = 3]) were asked to independently rate RV characteristics (global function, dilation, and septal flattening) based on standardized echocardiography images. We randomly selected 60 infants, ≥35 weeks gestation at birth, of whom 30 were clinically unwell with acute pulmonary hypertension (aPH) and 30 were healthy controls. aPH was defined by echocardiography presence of right-left shunting across transitional shunts or elevated right ventricular systolic pressure as estimated by the magnitude of the regurgitant jet across the tricuspid valve with impaired oxygenation. Inter-rater comparative evaluation within groups and between groups was performed using Kappa statistics.
Global agreement between evaluators for subjective assessment of RV function (0.3 [0.03], P < 0.001), size (0.14 [0.02], P < 0.001), and septal flattening (0.2 [0.02], P < 0.001) was uniformly poor. Agreement in RV function assessment was marginally better for both expert (0.32 [0.08], P < 0.001 vs 0.13 [0.081], and P < 0.001) and novice (0.4 [0.08], P < 0.001 vs 0.06 [0.07], and P < 0.001) evaluators. Overall, the diagnosis of aPH vs control was misclassified in 18% of cases.
This study demonstrated significant variability in qualitative assessment of RV size and function by trained evaluators, regardless of level of expertise attained. The reliability of objective measures of RV hemodynamics requires prospective evaluation.
新生儿超声心动图对右心室（RV）功能的主观评估缺乏验证。疑似肺动脉高压（PH）患者的错误诊断可能导致不必要的治疗或错过治疗机会。
六位评估者（专家[n = 3]，新手[n = 3]）被要求根据标准化超声心动图图像独立评估RV特征（整体功能、扩张和室间隔扁平）。我们随机选择了60名出生时胎龄≥35周的婴儿，其中30名患有急性肺动脉高压（aPH）且临床情况不佳，30名是健康对照。aPH通过超声心动图显示经过渡性分流的左右分流或根据三尖瓣反流束大小估计的右心室收缩压升高且伴有氧合受损来定义。使用Kappa统计量在组内和组间进行评估者间的比较评估。
评估者之间在RV功能主观评估（0.3[0.03]，P < 0.001）、大小（0.14[0.02]，P < 0.001）和室间隔扁平（0.2[0.02]，P < 0.001）方面的总体一致性均较差。专家评估者（0.32[0.08]，P < 0.001对比0.13[0.081]，P < 0.001）和新手评估者（0.4[0.08]，P < 0.001对比0.06[0.07]，P < 0.001）在RV功能评估方面的一致性略好。总体而言，18%的病例中aPH与对照的诊断被错误分类。
本研究表明，无论专业水平如何，训练有素的评估者在RV大小和功能的定性评估中存在显著差异。RV血流动力学客观测量的可靠性需要进行前瞻性评估。
