Development and Validation of a Teaching Module for Echocardiographic Scoring of Rheumatic Mitral Stenosis

The Wilkins score and commissural calcification scores predict outcomes after percutaneous balloon mitral valvuloplasty. However, many cardiologists are inadequately trained in their application-both in the United States where the incidence of rheumatic heart disease has fallen and in rheumatic heart disease endemic countries where training infrastructure is weak.

This study sought to develop a computer-based educational module teaching 2 scoring systems for rheumatic mitral stenosis and to validate the module among cardiology fellows in the United States and Uganda.

We developed a module organized into 3 sets of 10 echocardiograms each. The module was completed by 13 cardiology fellows from 2 academic centers in the United States and 1 in Uganda. Subject answers were compared with a score assigned by 2 experts in echocardiography. The primary outcome was change in subjects' accuracy from set 1 to set 3, measured by mean absolute deviation from expert scores. Secondary outcomes included change in interoperator variability and individual subject bias from set 1 to set 3.

The mean absolute deviations from expert scores in sets 1 and 3 were 2.09 and 1.82 for the Wilkins score (possible score range 0 to 16) and 1.13 and 0.94 for the commissural calcification score (possible score range 0 to 4). The change from set 1 to set 3 was statistically significant only for 1 of the Wilkins component scores (leaflet calcification, p < 0.001.) No change was seen in the interoperator variability. Individual subject bias in assigning the total Wilkins score was reduced from set 1 to set 3.

Use of this module has the potential to enhance the training of cardiologists in the echocardiographic assessment of mitral stenosis. Modified versions of this module or similar ones should be tested in targeted populations of cardiology trainees with the most exposure to mitral stenosis interventions.