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.
Karthik Seetharam, Nobuyuki Kagiyama and Partho P Sengupta
Victoria Pettemerides, Thomas Jake Turner, Conor Steele and Anita Macnab
Introduction: 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.
Methods: 1815 patients were referred to the 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 cardiac events (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 two years.
Results: 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 9 deaths (8 non-cardiac deaths and 1 cardiac death). MACE occurred in 4 patients with a mean time of 17.5 months (11.6–23.7 months). The annual event rate was 0.6%.
Conclusion: A negative stress echocardiogram can reliably reassure patients and clinicians even in high pre-test probability populations with suspected stable angina. It can continue to be used to post CG95.
Richard P Steeds, Craig E Stiles, Vishal Sharma, John B Chambers, Guy Lloyd and William Drake
This is a joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology on the role of echocardiography in monitoring patients receiving dopamine agonist (DA) therapy for hyperprolactinaemia. (1) Evidence that DA pharmacotherapy causes abnormal valve morphology and dysfunction at doses used in the management of hyperprolactinaemia is extremely limited. Evidence of clinically significant valve pathology is absent, except for isolated case reports around which questions remain. (2) Attributing change in degree of valvular regurgitation, especially in mild and moderate tricuspid regurgitation, to adverse effects of DA in hyperprolactinaemia should be avoided if there are no associated pathological changes in leaflet thickness, restriction or retraction. It must be noted that even where morphological change in leaflet structure and function may be suspected, grading is semi-quantitative on echocardiography and may vary between different machines, ultrasound settings and operators. (3) Decisions regarding discontinuation of medication should only be made after review of serial imaging by an echocardiographer experienced in analysing drug-induced valvulopathy or carcinoid heart disease. (4) A standard transthoracic echocardiogram should be performed before a patient starts DA therapy for hyperprolactinaemia. Repeat transthoracic echocardiography should then be performed at 5 years after starting cabergoline in patients taking a total weekly dose less than or equal to 2 mg. If there has been no change on the 5-year scan, repeat echocardiography could continue at 5-yearly intervals. If a patient is taking more than a total weekly dose of 2 mg, then annual echocardiography is recommended.
R Bedair and X Iriart
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect, affecting 3 in 10,000 live births. Surgical correction in early childhood is associated with good outcomes, but lifelong follow-up is necessary to identify the long-term sequelae that may occur. This article will cover the diagnosis of TOF in childhood, the objectives of surveillance through adulthood and the value of multi-modality imaging in identifying and guiding timely surgical and percutaneous interventions.
Hannah Bellsham-Revell and Navroz Masani
Sequential segmental analysis allows clear description of the cardiac structure in a logical fashion without assumptions and confusing nomenclature. Each segment is analysed, and then the connections described followed by any associated anomalies. For the echocardiographer there are several key features of the cardiac structures to help differentiate and accurately describe them.
John B Chambers, Madalina Garbi, Norman Briffa, Vishal Sharma and Richard P Steeds
Echocardiography plays a vital role in the follow-up of patients with replacement heart valves. However, there is considerable variation in international guidelines regarding the recommended time points after implantation at which routine echocardiography should be performed. The purpose of routine echocardiography is to detect early structural valve deterioration in biological valves to improve the timing of redo interventions. However, the risk of valve deterioration depends on many valve-related factors (valve design and patient prosthesis mismatch) and patient-related factors (age, diabetes, systemic hypertension, renal dysfunction and smoking). In this statement, the British Heart Valve Society and the British Society of Echocardiography suggest practical guidance. A plan should be made soon after implantation, but this may need to be modified for individual patients and as circumstances change. It is important that patients are managed in a multidisciplinary valve clinic.
Michael Roshen, Sophia John, Selda Ahmet, Rajiv Amersey, Sandy Gupta and George Collins
The British Society of Echocardiography (BSE) highlights the importance of patient questionnaires as part of the quality improvement process, To this end, we implemented a novel system whereby paired surveys were completed by patients and physiologists for transthoracic echocardiography scans, allowing for parallel comparison of the experiences of service providers and end users. Anonymised questionnaires were completed for each scan by the patient and physiologist for outpatient echocardiographic scans in a teaching hospital. In 26% of the responses, patient found the scans at least slightly painful, and in 24% of scans physiologists were in discomfort. The most common reason given by physiologists for technically difficult or inadequate scans was patient discomfort. In 38% of the scans at least one person (the patient or the physiologist) was in at least some discomfort. Comparative data showed that the scans reported as most painful by patients were also reported by the physiologists as difficult and uncomfortable. In summary, these results demonstrate the feasibility of implementing paired surveys. Patient information leaflets by the BSE and National Health Service (NHS) describe echocardiography as painless but the results here indicate this is not always the case.
H C Sinclair, P Russhard, C H Critoph and C D Steadman
A 70-year-old female with exertional dyspnoea was found to have basal septal hypertrophy (BSH), or a ‘basal septal bulge’, with evidence of mild left ventricular outflow tract obstruction (LVOT) at rest on her initial echocardiogram. She was usually fit and well with no significant past medical history. She had no history of hypertension. She had never smoked. There was no family history of hypertrophic cardiomyopathy (HCM). A cardiac MRI did not demonstrate any typical features of HCM. ECG showed sinus tachycardia with a rate of 101 bpm but was otherwise unremarkable. She was referred for exercise echocardiography to assess for latent LVOT obstruction. Prior to commencing exercise, her LVOT gradient was re-assessed at rest. Her LVOT gradients were 30 mmHg at rest, 49 mmHg during Valsalva and 91 mmHg on standing. A diagnosis of significant latent LVOT obstruction was made and the patient was started on bisoprolol, a cardioselective beta-blocker. Bisoprolol was slowly uptitrated from 1.25 mg to 5 mg once daily, following which the patient reported a significant improvement in her symptoms with an improved exercise capacity. Follow-up echocardiography demonstrated a dramatic reduction in LVOT gradient, with a maximum of 11 mmHg assessed both with Valsalva and on standing. This case is a reminder that patients with a ‘common’ basal septal bulge can develop significant LVOT obstruction, the symptoms of which may respond to pharmacological therapy. Orthostatic assessment of LVOT gradient using echocardiography should be considered during standard LVOT obstruction provocation manoeuvres such as a Valsalva.
Differentiation between basal septal hypertrophy (BSH) and hypertrophic cardiomyopathy (HCM) may be challenging. Key factors favouring HCM include a positive family history of HCM or sudden cardiac death, septal thickness >15 mm/posterior wall thickness >11 mm, systolic anterior motion of the anterior mitral valve (SAM), late gadolinium enhancement on cardiac MRI, a causative genetic mutation associated with HCM and an abnormal ECG.
Significant LVOT obstruction may develop in patients with BSH and is potentially responsive to pharmacotherapy.
Standing reduces venous return, resulting in decreased LV volume. Compensatory mechanisms to maintain cardiac output involve sympathetic nervous system activation leading to increased LV contractility and subsequent increased LVOT gradient.
Significant LVOT obstruction may be unmasked by an orthostatic posture.
Orthostatic LVOT gradient assessment should be part of the routine echocardiographic assessment of all patients with an increased LVOT gradient at rest.
The post-prandial state has been associated with increased LVOT gradient due to splanchnic dilatation and the consequent increased cardiac output required to maintain blood pressure. Post-prandial status should therefore be considered when assessing LVOT gradient.
Jack Parnell, Mehak Tahir and Benoy Nalin Shah
A 62-year-old man admitted with palpitations had a 12-lead ECG that revealed atrial flutter with 2:1 AV block (rate 150bpm). Transthoracic echocardiography (TTE) revealed normal left ventricular size with impaired systolic function and severe MR. No MV prolapse was seen. The admitting doctor informed the patient that mitral valve surgery was the likely outcome. However, after senior review, the patient was commenced on rate-control, diuretic and anticoagulant medications. He was discharged and returned six weeks later for direct current cardioversion, which successfully restored sinus rhythm. TTE two months later showed normal LV function and trivial MR. This case highlights the importance of understanding the mechanism underlying MV dysfunction. The mitral annulus is a thin fibrofatty ring that geometrically resembles a parabola; its sphincteric contraction reduces MV annular area by ∼25% during the cardiac cycle, facilitating normal leaflet coaptation. Consequently, the onset of atrial flutter – and loss of annular contraction – resulted in MR and this was exacerbated by the rapid heart rate, which reduces the normal ventricular closing forces on the valve leading to incomplete mitral leaflet coaptation. Clinicians are reminded that atrial arrhythmias with high heart rates can disrupt normal MV function, producing MR which can be resolved by treating the underlying abnormality (i.e. atrial arrhythmia) and thus avoiding unnecessary cardiac surgery.