A technology based on velocity ratio indices is described for application in the myocardium. Angle-independent Doppler indices, such as the pulsatility index, which employ velocity ratios, can be measured even if the ultrasound beam vector at the moving target and the motion vector are not in a known plane. The unknown plane situation is often encountered when an ultrasound beam interrogates sites in the myocardium. The velocities employed in an index calculation must be close to the same or opposite directions. The Doppler velocity ratio indices are independent of angle in 3D space as are ratio indices based on 1D strain and 1D speckle tracking. Angle-independent results with spectral Doppler methods are discussed. Possible future imaging techniques based on velocity ratios are presented. By using indices that involve ratios, several other sources of error cancel in addition to that of angular dependence for example errors due to less than optimum gain settings and beam distortion. This makes the indices reliable as research or clinical tools. Ratio techniques can be readily implemented with current commercial blood flow pulsed wave duplex Doppler equipment or with pulsed wave tissue Doppler equipment. In 70 patients where the quality of the real-time B-mode looked suitable for the Doppler velocity ratio technique, there was only one case where clear spectra could not be obtained for both the LV wall and the septum. A reproducibility study of spectra from the septum of the heart shows a 12% difference in velocity ratios in the repeat measurements.
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Norman McDicken, Adrian Thomson, Audrey White, Iqbal Toor, Gillian Gray, Carmel Moran, Robin J Watson and Tom Anderson
Viren Ahluwalia, Faizel Osman, Jitendra Parmar and Jamal Nasir Khan
Despite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilised in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume-rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3D-TOE under sedation. This led to timely surgery and an excellent outcome for the patient.
- 3DE is of greater clinical value than 2DE as it is able to post-process a single 3DE image acquisition into volume rendered 3D models, and provide an unlimited number of multiplanar reconstruction (MPR) images.
- 3DE is highly effective in difficult cases where speed is important.
- 3DE is superior in the planning of complex surgical cases.
Gowsini Joseph, Tomas Zaremba, Martin Berg Johansen, Sarah Ekeloef, Einar Heiberg, Henrik Engblom, Svend Eggert Jensen and Peter Sogaard
The aim of this study was to investigate if there was an association between infarct size (IS) measured by cardiac magnetic resonance (CMR) and echocardiographic global longitudinal strain (GLS) in the early stage of acute myocardial infarction in patients with preserved left ventricular ejection fraction (LVEF). Patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were assessed with CMR and transthoracic echocardiogram within 1 week of hospital admission. Two-dimensional speckle tracking was performed using a semi-automatic algorithm (EchoPac, GE Healthcare). Longitudinal strain curves were generated in a 17-segment model covering the entire left ventricular myocardium. GLS was calculated automatically. LVEF was measured by auto-LVEF in EchoPac. IS was measured by late gadolinium enhancement CMR in short-axis views covering the left ventricle. The study population consisted of 49 patients (age 60.4 ± 9.7 years; 92% male). The study population had preserved echocardiographic LVEF with a mean of 45.8 ± 8.7%. For each percent increase of IS, we found an impairment in GLS by 1.59% (95% CI 0.57–2.61), P = 0.02, after adjustment for sex, age and LVEF. No significant association between IS and echocardiographic LVEF was found: −0.25 (95% CI: −0.61 to 0.11), P = 0.51. At the segmental level, the strongest association between IS and longitudinal strain was found in the apical part of the LV: impairment of 1.69% (95% CI: 1.14–2.23), P < 0.001, for each percent increase in IS. In conclusion, GLS was significantly associated with IS in the early stage of acute myocardial infarction in patients with preserved LVEF, and this association was strongest in the apical part of the LV. No association between IS and LVEF was found.
Kuberan Pushparajah, Phuoc Duong, Sujeev Mathur and Sonya V Babu-Narayan
Cardiac MRI and CT are increasingly used in the diagnosis and management of patients with congenital heart disease as an imaging adjunct to echocardiography. The benefits and limitations of both modalities are highlighted, with a focus on the anatomical, functional and haemodynamic information that can be gained from the different modalities. Deciding on the imaging modality of choice must also take into account patient factors such as age, compliance, the type of congenital heart disease, and previous procedures. Future developments in CT and MRI are also discussed.
Meryl S Cohen and Luc L Mertens
Echocardiographic assessment of patients with transposition of the great arteries and congenitally corrected transposition requires awareness of the morphology and commonly associated lesions. The pre-operative echocardiography should include a full segmental and sequential analysis. Post-operative assessment is not possible without awareness of the type of surgical procedure performed and consists of assessing surgical connections and residual lesions.
David Messika-Zeitoun, Ian G Burwash and Thierry Mesana
Valvular heart disease (VHD) is responsible for a major societal and economic burden. Incidence and prevalence of VHD are high and increase as the population ages, creating the next epidemic. In Western countries, the etiology is mostly degenerative or functional disease and strikes an elderly population with multiple comorbidities. Epidemiological studies have shown that VHD is commonly underdiagnosed, leading to patients presenting late in their disease course, to an excess risk of mortality and morbidity and to a missed opportunity for intervention. Once diagnosed, VHD is often undertreated with patients unduly denied intervention, the only available curative treatment. This gap between current recommendations and clinical practice and the marked under-treatment is at least partially related to poor knowledge of current National and International Societies Guidelines. Development of a valvular heart team involving multidisciplinary valve specialists including clinicians, imaging specialists, interventional cardiologists and surgeons is expected to fill these gaps and to offer an integrated care addressing all issues of patient management from evaluation, risk-assessment, decision-making and performance of state-of-the-art surgical and transcatheter interventions. The valvular heart team will select the right treatment for the right patient, improving cost-effectiveness and ultimately patients’ outcomes.
John B Chambers and Richard P Steeds
As heart valve disease increases in prevalence in an ageing population, comorbidities make patients increasingly hard to assess. Specialist competencies are therefore increasingly important to deliver best practice in a specialist valve clinic and to make best advantage of advances in percutaneous and surgical interventions. However, patient care is not improved unless all disciplines have specialist valve competencies, and there is little guidance about the practical details of running a specialist valve clinic. In this issue of Echo Research and Practice, the British Heart Valve Society (BHVS) and the British Society of Echocardiography (BSE) introduce a series of articles to guide all disciplines in how to run a valve clinic.
John B Chambers
Echocardiography is the key to the detection and initial assessment of valve disease. The examination helps differentiate severe from moderate disease if this is unclear from the echocardiogram, but is less useful than echocardiography for surveillance. However, the history is extremely important because symptoms are an indication for surgery in all types of valve disease. In aortic stenosis, the mortality rises soon after the onset of exertional breathlessness or chest tightness. Exercise testing is an extension of the history and may reveal symptoms in apparently asymptomatic patients. This article discusses the history, examination and exercise testing in patients either newly referred or under routine follow-up in a specialist valve clinic.
Erwan Donal, Elena Galli, Amedeo Anselmi, Auriane Bidaut and Guillaume Leurent
In this review, we discuss the central role of the imager in the heart team in the successful application of current guidelines for heart valve diseases to daily practice, and for improving patient care through new approaches, new techniques and new strategies for dealing with increasingly complex cases. This is an opportunity to emphasize the importance of having good imagers and the value of continuous learning in a modern heart team. It is essential to employ technological improvements and to appropriately adapt guidelines to the patients we see day to day.
Sanjeev Bhattacharyya, Denise Parkin and Keith Pearce
The prevalence of heart valve disease is increasing as the population ages. A series of studies have shown current clinical practice is sub-optimal. Some patients are referred for surgery at advanced stages of disease with impaired ventricular function or not even considered for surgery. Valve clinics seek to improve patient outcomes by providing an expert-led, patient-centred framework of care designed to provide an accurate diagnosis with active surveillance of valve pathology and timely referral for intervention at guideline directed trigger points. A range of different valve clinic models can be adopted depending on local expertise combining the skill set of cardiologist, physiologist/scientist and nurses. Essential components to all clinics include structured clinical review, echocardiography to identify disease aetiology and severity, patient education and access to both additional diagnostic testing and a multi-disciplinary meeting for complex case review. Recommendations for training in heart valve disease are being developed. There is a growing evidence base for heart valve clinics providing better care with increased adherence to guideline recommendations, more timely referral for surgery and better patient education than conventional care.