Stress echocardiography is a widely utilised test in patients with known or suspected coronary artery disease (CAD), valvular heart disease and cardiomyopathies. Its advantages include the ubiquitous availability of echocardiography, lack of ionising radiation, choice of physiological or pharmacological stressors, good diagnostic accuracy and robust supporting evidence base. SE has evolved significantly as a technique over the past three decades and has benefitted considerably from improvements in overall image quality (superior resolution), machine technology (e.g. digital cine-loop acquisition and side-by-side image display) and development of second-generation ultrasound contrast agents that have improved reader confidence and diagnostic accuracy. The purpose of this article is to review the breadth of SE in contemporary clinical cardiology and discuss the recently launched British Society of Echocardiography (BSE) Stress Echocardiography accreditation scheme.
Benoy N Shah, Anita MacNab, Jane Lynch, Reinette Hampson, Roxy Senior, and Richard P Steeds
Daniel Hammersley, Aamir Shamsi, Mohammad Murtaza Zaman, Philip Berry, and Lydia Sturridge
A 63-year-old female presented to hospital with progressive exertional dyspnoea over a 6-month period. In the year preceding her admission, she reported an intercurrent history of abdominal pain, diarrhoea and weight loss. She was found to be hypoxic, the cause for which was initially unclear. A ventilation–perfusion scan identified a right-to-left shunt. Transoesophageal echocardiography (TOE) demonstrated a significant right-to-left intracardiac shunt through a patent foramen ovale (PFO); additionally severe tricuspid regurgitation was noted through a highly abnormal tricuspid valve. The findings were consistent with carcinoid heart disease with a haemodynamically significant shunt, resulting in profound systemic hypoxia. 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) and imaging were consistent with a terminal ileal primary carcinoid cancer with hepatic metastasis. Liver biopsy confirmed a tissue diagnosis. The patient was commenced on medical therapy for carcinoid syndrome. She subsequently passed away while undergoing anaesthetic induction for valvular surgery to treat her carcinoid heart disease and PFO.
Carcinoid syndrome is a rare condition, which presents a significant diagnostic challenge due to its insidious presentation and symptoms. This frequently results in a marked delay in diagnosis.
Carcinoid heart disease is characterised by distortion and fixation of right-sided heart valves, which cause valvular regurgitation, stenosis or both. Valvular abnormalities are often found in association with right ventricular failure.
In the case described, carcinoid heart disease was found in association with a significant right-to-left intracardiac shunt, created through a PFO due to right atrial volume overload. This prevented right ventricular failure at the expense of creating a state of severe induced systemic hypoxia.
This physiological adaptation resulted in an unusual presentation of this condition, due to symptoms resulting from hypoxia, rather than the classical symptoms of carcinoid syndrome or right ventricular failure.
Corstiaan A den Uil, Mihai Strachinaru, Ben van der Hoven, and J Han J Meeder
Xiu-Xia Luo, Fang Fang, Hung-Kwan So, Chao Liu, Man-Ching Yam, and Alex Pui-Wai Lee
Several studies have reported the accuracy and reproducibility of HeartModel for automated determination of three-dimensional echocardiography (3DE)-derived left heart volumes and left ventricular (LV) ejection fraction (LVEF) in adult patients. However, it remains unclear whether this automated adaptive analytics algorithm, derived from a ‘training’ population, can encompass adequate echo images in Chinese adolescents.
The aim of our study was to explore the accuracy of HeartModel in adolescents compared with expert manual three-dimensional (3D) echocardiography.
Fifty-three Chinese adolescent subjects with or without heart disease underwent 3D echocardiographic imaging with an EPIQ system (Philips). 3D cardiac volumes and LVEF obtained with the automated HeartModel program were compared with manual 3D echocardiographic measurements by an experienced echocardiographer.
There was strong correlation between HeartModel and expert manual 3DE measurements (r = 0.875–0.965, all P < 0.001). Automated LV and left atrial (LA) volumes were slightly overestimated when compared to expert manual measurements, while LVEF showed no significant differences from the manual method. Importantly, the intra- and inter-observer variability of automated 3D echocardiographic model was relatively low (<1%), surpassing the manual approach (3.5–17.4%), yet requiring significantly less analyzing time (20 ± 7 vs 177 ± 30 s, P < 0.001).
Simultaneous quantification of left heart volumes and LVEF with the automated HeartModel program is rapid, accurate and reproducible in Chinese adolescent cohort. Therefore, it has a potential to bring 3D echocardiographic assessment of left heart chamber volumes and function into busy pediatric practice.
The advancement of echocardiography in the past two decades is more than downsizing of the machines and improvement of image quality, but introduction of new imaging modalities leading to the ability of performing quantitative analysis. This function is greatly facilitated by the integration of echo machines with high performance computers, software programming and establishment of workstation for offline analysis. Today, echo examination is more than estimation of ejection fraction (EF) and patterns of left ventricular (LV) diastolic dysfunction. Echosonographers are facing a large number of quantitative parameters for interpretation. In newer imaging modalities such as tissue Doppler imaging, speckle tracking, 3-dimensional echocardiography and 3D-transoesophageal echocardiography, quantitative echocardiographic assessment has important roles. These have brought many opportunities but also challenges in our echo practice.
Benoy N Shah and Dhrubo J Rakhit
Anne Ringle, Anne Dornhorst, Michaela B Rehman, Cristina Ruisanchez, and Petros Nihoyannopoulos
We sought to assess the long-term evolution of left ventricular (LV) function using two-dimensional (2D) and three-dimensional (3D) speckle tracking echocardiography (STE) for the detection of preclinical diabetic cardiomyopathy, in asymptomatic type 1 diabetic patients, over a 6-year follow-up.
Design and methods
Sixty-six asymptomatic type 1 diabetic patients with no cardiovascular risk factors were compared to 26 matched healthy controls. Conventional, 2D and 3D-STE were performed at baseline. A subgroup of 14 patients underwent a 6-year follow-up evaluation.
At baseline, diabetic patients had similar LV ejection fraction (60 vs 61%; P = NS), but impaired longitudinal function, as assessed by 2D-global longitudinal strain (GLS) (−18.9 ± 2 vs −20.5 ± 2; P = 0.0002) and 3D-GLS (−17.5 ± 2 vs −19 ± 2; P = 0.003). At follow-up, diabetic patients had worsened longitudinal function compared to baseline (2D-GLS: −18.4 ± 1 vs −19.2 ± 1; P = 0.03). Global circumferential (GCS) and radial (GRS) strains were unchanged at baseline and during follow-up. Metabolic status did not correlate with GLS, whereas GCS and GRS showed a good correlation, suggestive of a compensatory increase of circumferential and radial functions in advanced stages of the disease – long-term diabetes (GCS: −26 ± 3 vs −23.3 ± 3; P = 0.008) and in the presence of microvascular complications (GRS: 38.8 ± 9 vs 34.3 ± 8; P = 0.04).
Subclinical myocardial dysfunction can be detected by 2D and 3D-STE in type 1 diabetic patients, independently of any other cardiovascular risk factors. Diabetic cardiomyopathy progression was suggested by a mild decrease in longitudinal function at the follow-up, but did not extend to a clinical expression of the disease, as no death or over heart failure was reported.
Camelia Demetrescu, Shelley Rahman Haley, and Aigul Baltabaeva
We present the case of a previously fit 84-year-old female with long-standing systemic hypertension and the echo phenotype of hypertrophic cardiomyopathy (HCM) – asymmetrical septal hypertrophy, significant resting left ventricular (LV) outflow obstruction and mitral regurgitation (MR) secondary to systolic anterior motion (SAM) of the mitral valve. Valsalva provocation caused an increase in LVOT dynamic gradient and MR severity. The patient presented with a progressive decrease in exercise capacity along with chest pain relieved by rest or sublingual GTN. Exercise stress echo demonstrated a paradoxical response with reduction of both LVOT gradient and severity of MR. There was evidence of inducible regional wall motion abnormalities associated with no change in LV cavity size. Coronary angiogram revealed significant triple vessel disease.
20% of adult HCM patients over the age of 45 years have been shown to have coexistent coronary artery disease (CAD) that is associated with a reduced overall survival. Diagnosis of CAD in patients with HCM is difficult to make based on clinical grounds because of the high incidence of angina in patients with HCM but no CAD.
Reduction of LVOT gradient with stress in patients with HCM (in the absence of a vaso-vagal response) may indicate ischaemia due to significant multivessel epicardial CAD, including left mainstem stenosis. Hence, this finding during stress echocardiography suggests that further investigation of the coronaries should be considered.
Exercise stress echocardiography has not been validated for the assessment of ischaemia secondary to epicardial coronary disease in patients with HCM because ischaemia in this group of patients is often caused by multiple mechanisms, including microvascular ischaemia and myocardial bridging.
Comparative assessment of rest and peak exercise 2D strain may add incremental value in identifying regional wall motion abnormalities, which may be difficult to distinguish by eye in hypertrophied, dynamic myocardium.
A paradoxical response to exercise with significant decrease in LVOT obstruction and MR has been reported in the literature. This is often associated with a trend toward increased exercise capacity and better prognostic outcomes. Our clinical case presents a significant decrease in LVOT obstruction and MR that was associated with a trend toward reduced exercise capacity and was caused by ischaemia.
V S Ellensen, S Saeed, T Geisner, and R Haaverstad
We present a rare complication of deep venous thrombosis with pulmonary embolism that threatened the patient with systemic embolization. A 36-year-old female was referred to the hospital after five days of progressive shortness of breath and chest pain. Preceding onset of symptoms, she had undergone surgery leading to reduced physical activity and had just returned from vacation by a long flight. Investigations with transthoracic and transesophageal echocardiography revealed a thromboembolism-in-transit across a patent foramen ovale. Thoracic CT showed submassive bilateral pulmonary embolism. Hemodynamic parameters were stable. The patient was treated surgically with extraction of the thrombus, closure of the foramen ovale and removal of the bilateral pulmonary emboli. She was discharged after an uneventful hospital stay.
Thromboembolism-in-transit across a patent foramen ovale usually occurs in the presence of deep venous thrombosis with pulmonary embolism. The abrupt rise in pulmonary arterial pressure may contribute to the migration of the thrombus across the atrial septum to the systemic circulation.
If any abnormal structures are seen in the left atrium by TTE in a patient with pulmonary embolism, a TEE should be performed to rule out an embolus entrapped in a patent foramen ovale.
When acute pulmonary hypertension cannot be assessed by conventional methods, additional parameters such as shortened right ventricular outflow tract acceleration time and a mid-systolic notching of the pulse wave Doppler profile in the right ventricular outflow tract may be useful.
Mortality is highest during the initial 24 h after onset of chest symptoms; thus, optimal treatment must commence urgently.
The choice of treatment in each individual patient must be made after a thorough discussion in a multidisciplinary heart team.