Sothinathan Gurunathan and Roxy Senior
Victoria Pettemerides and Anita Macnab
Sahrai Saeed, Eva Gerdts, Ulrike Waje-Andreassen, Juha Sinisalo, and Jukka Putaala
The incidence of ischemic stroke in young patients is increasing and associated with unfavorable prognosis due to high risk of recurrent cardiovascular events. In many young patients the cause of stroke remains unknown, referred to as cryptogenic stroke. Neuroimaging frequently suggests a proximal source of embolism in these strokes. We developed a comprehensive step-by-step echocardiography protocol for a prospective study with centralized reading to characterize preclinical cardiac changes associated with cryptogenic stroke.
Methods and study design
SECRETO (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome; NCT01934725) is an ongoing multicenter case–control study enrolling patients (target n = 600) aged 18–49 years hospitalized due to first-ever ischemic stroke of undetermined etiology and age- and sex-matched controls (target n = 600). A comprehensive assessment of cardiovascular risk factors and extensive cardiac imaging with transthoracic and transesophageal echocardiography, electrocardiography and neurovascular imaging is performed. Transthoracic and transesophageal echocardiograms will be centrally read, following an extensive protocol particularly emphasizing the characteristics of left atrium, left atrial appendage and interatrial septum.
A detailed assessment of both conventional and unconventional vascular risk factors and cardiac imaging with transthoracic and transesophageal echocardiography are implemented in SECRETO, aiming to establish indirect and direct risk factors and causes for cryptogenic stroke and novel pathophysiological brain–heart pathways. This may ultimately enable more personalized therapeutic options for these patients.
Karthik Seetharam, Nobuyuki Kagiyama, and Partho P Sengupta
The intersection of global broadband technology and miniaturized high-capability computing devices has led to a revolution in the delivery of healthcare and the birth of telemedicine and mobile health (mHealth). Rapid advances in handheld imaging devices with other mHealth devices such as smartphone apps and wearable devices are making great strides in the field of cardiovascular imaging like never before. Although these technologies offer a bright promise in cardiovascular imaging, it is far from straightforward. The massive data influx from telemedicine and mHealth including cardiovascular imaging supersedes the existing capabilities of current healthcare system and statistical software. Artificial intelligence with machine learning is the one and only way to navigate through this complex maze of the data influx through various approaches. Deep learning techniques are further expanding their role by image recognition and automated measurements. Artificial intelligence provides limitless opportunity to rigorously analyze data. As we move forward, the futures of mHealth, telemedicine and artificial intelligence are increasingly becoming intertwined to give rise to precision medicine.
Arturo Evangelista, Giuliana Maldonado, Domenico Gruosso, Laura Gutiérrez, Chiara Granato, Nicolas Villalva, Laura Galian, Teresa González-Alujas, Gisela Teixido, and Jose Rodríguez-Palomares
Acute aortic syndrome (AAS) comprises a range of interrelated conditions caused by disruption of the medial layer of the aortic wall, including aortic dissection, intramural haematoma and penetrating aortic ulcer. Since mortality from AAS is high, a prompt and accurate diagnosis using imaging techniques is paramount. Both transthoracic (TTE) and transoesophageal echocardiography (TEE) are useful in the diagnosis of AAS. TTE should be the first imaging technique to evaluate patients with thoracic pain in the emergency room. Should AAS be suspected, contrast administration is recommended when images are not definitive. TEE allows high-quality images in thoracic aorta. The main drawback of this technique is that it is semi-invasive and the presence of a blind area that limits visualisation of the distal ascending aorta near. TEE identifies the location and size of the entry tear, secondary communications, true lumen compression and the dynamic flow pattern of false lumen. Although computed tomography (CT) is the most used imaging technique in the diagnosis of AAS, echocardiography offers complementary information relevant for its management. The best imaging strategy for appropriately diagnosing and assessing AAS is to combine CT, mainly ECG-gated contrast-enhanced CT, and TTE. Currently, TEE tends to be carried out in the operating theatre immediately before surgical or endovascular therapy and in monitoring their results. The aims of this review are to establish the current role of echocardiography in the diagnosis and management of AAS based on its advantages and limitations.
Victoria Pettemerides, Thomas Turner, Conor Steele, and Anita Macnab
The 2016 NICE clinical guideline 95 (CG95) demoted functional imaging to a second-line test following computed tomography coronary angiography (CTCA). Many cardiac CT services in the UK require substantial investment and growth to implement this. Chest pain services like ours are likely to continue to use stress testing for the foreseeable future. We share service evaluation data from our department to show that a negative stress echocardiogram can continue to be used for chest pain assessment.
1815 patients were referred to rapid access chest pain clinic (RACPC) between June 2013 and March 2015. 802 patients had stress echocardiography as the initial investigation. 446 patients had normal resting left ventricular (LV) systolic function and a negative stress echocardiogram. At least 24 months after discharge, a survey was carried out to detect major adverse cardiovascular events (MACE) (cardiac death, myocardial infarction, admission to hospital for heart failure or angina, coronary artery disease at angiography, revascularisation by angioplasty or coronary artery bypass grafting) within 2 years.
Overall, 351 patients were successfully followed up. The mean Diamond-Forrester (D-F) score and QRISK2 suggested a high pre-test probability (PTP) of coronary artery disease (CAD). There were nine deaths (eight non-cardiac deaths and one cardiac death). MACE occurred in four patients with a mean time of 17.5 months (11.6–23.7 months). The annual event rate was 0.6%.
A negative stress echocardiogram can reliably reassure patients and clinicians even in high PTP populations with suspected stable angina. It can continue to be used to assess stable chest pain post CG95.
David G Platts, Kenji Shiino, Jonathan Chan, Darryl J Burstow, Gregory M Scalia, and John F Fraser
Transthoracic echocardiography (TTE) plays a fundamental role in the management of patients supported with extra-corporeal membrane oxygenation (ECMO). In light of fluctuating clinical states, serial monitoring of cardiac function is required. Formal quantification of ventricular parameters and myocardial mechanics offer benefit over qualitative assessment. The aim of this research was to compare unenhanced (UE) versus contrast-enhanced (CE) quantification of myocardial function and mechanics during ECMO in a validated ovine model.
Twenty-four sheep were commenced on peripheral veno-venous ECMO. Acute smoke-induced lung injury was induced in 21 sheep (3 controls). CE-TTE with Definity using Cadence Pulse Sequencing was performed. Two readers performed image analysis with TomTec Arena. End diastolic area (EDA, cm2), end systolic area (ESA, cm2), fractional area change (FAC, %), endocardial global circumferential strain (EGCS, %), myocardial global circumferential strain (MGCS, %), endocardial rotation (ER, degrees) and global radial strain (GRD, %) were evaluated for UE-TTE and CE-TTE.
Full data sets are available in 22 sheep (92%). Mean CE EDA and ESA were significantly larger than in unenhanced images. Mean FAC was almost identical between the two techniques. There was no significant difference between UE and CE EGCS, MGCS and ER. There was significant difference in GRS between imaging techniques. Unenhanced inter-observer variability was from 0.48–0.70 but significantly improved to 0.71–0.89 for contrast imaging in all echocardiographic parameters.
Semi-automated methods of myocardial function and mechanics using CE-TTE during ECMO was feasible and similar to UE-TTE for all parameters except ventricular areas and global radial strain. Addition of contrast significantly decreased inter-observer variability of all measurements.
John M Simpson and Annemien van den Bosch
Three-dimensional echocardiography is a valuable tool for the assessment of cardiac function where it permits calculation of chamber volume and function. The anatomy of valvar and septal structures can be presented in unique and intuitive ways to enhance surgical planning. Guidance of interventional procedures using the technique has now become established in many clinical settings. Enhancements of image processing to include intracavity flow, image fusion and true 3D displays look set to further improve the contribution of this modality to care of the patient with congenital heart disease.
Takahide Ito and Michihiro Suwa
Spontaneous echo contrast (SEC) indicates blood stasis in cardiac chambers and major vessels, and is a known precursor of thrombus formation. Transesophageal echocardiography plays a pivotal role in detecting and grading SEC in the left atrial (LA) cavity. Assessing LA SEC can identify patients at increased risk for thromboembolic events. LA SEC also develops in patients who have sinus rhythm, especially in those with heart failure. Detection of LA SEC is not uncommon in subjects who have multiple cardiovascular comorbidities, although mechanisms behind this association are not fully understood. In patients with atrial fibrillation, the role of mitral regurgitation in counteracting LA SEC and subsequent thromboembolism is controversial. Moreover, alterations of blood coagulability and elevated levels of certain biological markers in the blood contribute to occurrence of LA SEC. This review describes the pathogenesis and assessment of SEC, in addition to the relationship between LA SEC and clinical, biological and echocardiographic parameters.
I J Ingimarsdóttir, L Hellgren Johansson, and F A Flachskampf
The aortic annulus diameter measured by transthoracic echocardiography yields lower values than by computed tomography, and echo-based selection of transcatheter aortic valve prosthesis size has been implied to result in more frequent paravalvular leakage. We investigated the relation of preoperative annulus diameter by echo with the ring size of the aortic prosthesis chosen by direct assessment during open-heart aortic valve replacement.
Preoperative annulus diameter by echo (from parasternal long-axis cross-sections of the left ventricular outflow tract and aortic valve) and implanted prosthetic diameter (tissue annulus diameter, determined intraoperatively using a sizing instrument) were compared retrospectively in 285 consecutive patients undergoing open-heart aortic valve replacement.
A total of 285 prostheses (240 biologic and 45 mechanical) were implanted, with prosthetic diameter ranging between 19 and 27 mm. There was a significant linear correlation (P < 0.0001) with r = 0.51, between preoperative annulus diameter by echo (mean 21.8 ± 2.8 mm) and prosthetic diameter (22.9 ± 1.7 mm). Preoperative annulus diameter of patients receiving prostheses no. 21, 23 and 25 mm aortic prostheses (the most frequent prosthesis sizes) were significantly different (P < 0.001) from each other. On average, preoperative annulus diameter by echo underestimated prosthetic diameter by a bias of 1.07 mm.
Our data confirm that preoperative echo assessment of the aortic valve may slightly underestimates the optimal surgical prosthesis diameter for the aortic valve annulus.