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Open access

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.

Open access

Brian Campbell, Shaun Robinson and Bushra Rana

At its inception, transthoracic echocardiography (TTE) was employed as a basic screening tool for the diagnosis of heart valve disease and as a crude indicator of left ventricular function. Since then, echocardiography has developed into a highly valued non-invasive imaging technique capable of providing extremely complex data for the diagnosis of even the subtlest cardiac pathologies. Its role is now pivotal in the diagnosis and monitoring of heart disease. With the evolution of advanced practice and devolving care, ordinarily performed by senior doctors, to the cardiac physiology workforce in the UK, significant benefits in terms of timely patient care and cost savings are possible. However, there needs to be appropriate level of accountability. This accountability is achieved in the UK with statutory regulation of healthcare professionals and is a crucial element in the patient protection system, particularly for professions in patient facing roles. However, statutory regulation for staff practising echocardiography is not currently mandatory in the UK, despite the level of responsibility and influence on patient care. Regulators protect the public against the risk of poor practice by setting agreed standards of practice and competence and registering those who are competent to practice. Regulators take action if professionals on their register do not meet their standards. The current cardiac physiology workforce can be recognised as registered clinical scientists using equivalence process through the Academy for Healthcare Science, and this review aims to describe the process in detail.

Open access

Kawa Haji, Chiew Wong, Christopher Neil, Nicholas Cox, Andrew Mulligan, Leah Wright, Sara Vogrin and Thomas H Marwick

Background

Handheld ultrasound could provide sufficient information to satisfy the clinical questions underlying ‘rarely appropriate’ echo requests, but there are limited data about its use as a gatekeeper to standard echocardiography. We sought to determine whether the use of handheld ultrasound could improve the appropriate use of echocardiography.

Method

A prospective study comparing handheld ultrasound strategy to standard echocardiography for studies deemed rarely appropriate, using a questionnaire based on appropriate use criteria was conducted across two hospitals, from October 2017 to April 2018.

Results

Groups undergoing Handheld ultrasound (n = 76, 58 (46.5–72.5) years, 53 males, 78% outpatients) and standard echocardiography (n = 72, 61 (49.0–71.5) years, 42 males, 76% outpatients) were comparable. There was a significant decrease in the time to scan from just over 1 month in standard group to a median of 12 days in handheld ultrasound group (P < 0.001). This difference was small for inpatients (from 1 day to a median of 10 min in handheld ultrasound, P = 0.014), but prominent in outpatients (from 1.5 months in the standard group to median of 2 weeks in the handheld ultrasound group, P < 0.001). There was no increase in the need for follow-up scan within 6 months and no significant differences in length of hospital stay for inpatients.

Conclusion

Handheld ultrasound can be an effective gatekeeper to standard echocardiography for requests deemed rarely appropriate, reducing time to echocardiography significantly and potentially decreasing the need for standard echocardiography by up to 20%.

Open access

Jonathan Hinton, George Hunter, Madhava Dissanayake and Rob Hatrick

Summary

Pseudo-aneurysms are a rare, potentially life-threatening complication of a myocardial infarction. We present the case of a 45-year-old male who was brought to the emergency department in extremis and had a previous history of a late presentation inferior ST-elevation myocardial infarction treated percutaneously. Clinical examination revealed evidence of cardiogenic shock, pulmonary edema and a pulsatile epigastric mass. Chest X-ray demonstrated marked cardiomegaly and pulmonary edema. Urgent echocardiography confirmed the presence of a huge basal inferior wall pseudo-aneurysm with bi-directional flow. This was also associated with severe mitral regurgitation, due to posterior mitral annular involvement. The patient was transferred to the local cardiothoracic surgical unit where he underwent emergency repair of the pseudo-aneurysm and mitral valve replacement. Despite the surgery being complex he made a full recovery.

Open access

Hannah R Bellsham-Revell, Antigoni Deri, Silvia Caroli, Andrew Durward, Owen I Miller, Sujeev Mathur, Jelena Saundankar, David R Anderson, B Conal Austin, Caner Salih, Kuberan Pushparajah and John M Simpson

Background

The Technical Performance Score (TPS) developed by Boston Children’s Hospital showed surgical outcomes correlate with adequacy of technical repair when implemented on pre-discharge echocardiograms. We applied this scoring system to intraoperative imaging in a tertiary UK congenital heart surgical centre.

Methods

After a period of training, intraoperative TPS (epicardial and/or transesophageal echocardiography) was instituted. TPS was used to inform intraoperative discussions and recorded on a custom-made database using the previously published scoring system. After a year, we reviewed the feasibility, results and relationship between the TPS and mortality, extubation time and length of stay.

Results

From 01 September 2015 to 04 July 2016, there were 272 TPS procedures in 251 operations with 208 TPS recorded. Seven patients had surgery with no documented TPS, three had operations with no current TPS score template available. Patients left the operating theatre with TPS optimal in 156 (75%), adequate 34 (16%) and inadequate 18 (9%). Of those with an optimal score on leaving theatre, ten had more than one period of cardiopulmonary bypass. All four deaths <30 days after surgery (1.9%) had optimal TPS. There was a statistically significant difference in extubation times in the RACHS category 4 patients (3 days vs 5 days, P < 0.05) and in PICU and total length of stay in the RACHS category three patients (2 and 8 days vs 12.5 and 21.5 days respectively) if leaving theatre with an inadequate result.

Conclusions

Application of intraoperative TPS is feasible and provides a way of objectively recording intraoperative imaging assessment of surgery. An ‘inadequate’ TPS did not predict mortality but correlated with a longer ventilation time and longer length of stay compared to those with optimal or adequate scores.

Open access

V D Mathiasen, C A Frederiksen, C Wejse and S H Poulsen

Summary

Tuberculous pericarditis is a rare diagnosis seen among as few as 1% of tuberculosis (TB) patients in developed countries. We present a case of a 60-year-old male suffering from a transient constrictive pericarditis and subclinical involvement of the myocardium in a clinical case of tuberculous pericarditis with corresponding improvement after the initiation of anti-tuberculous treatment. We suggest monitoring of myocardial function using global longitudinal strain by myocardial speckle tracking strain analysis as supplement to routine left ventricular ejection fraction to assess clinical improvement in patients at risk of developing constrictive pericarditis.

Open access

Daniel X Augustine, Lindsay D Coates-Bradshaw, James Willis, Allan Harkness, Liam Ring, Julia Grapsa, Gerry Coghlan, Nikki Kaye, David Oxborough, Shaun Robinson, Julie Sandoval, Bushra S Rana, Anjana Siva, Petros Nihoyannopoulos, Luke S Howard, Kevin Fox, Sanjeev Bhattacharyya, Vishal Sharma, Richard P Steeds, Thomas Mathew and the British Society of Echocardiography Education Committee

Open access

Mary Mashicharan, Zein El-Dean, Viktor Zlocha and Jeffrey Khoo

Summary

Fibroelastomas are rare, primary cardiac tumours with a predilection for valvular endothelium and a propensity to embolise. We present the case of a 72-year-old male with multiple cerebrovascular events (CVA) despite oral anticoagulation. Transoesophageal echocardiography (TOE) revealed a small highly mobile left atrial mass with frond-like projections attached by a stalk to the orifice of the LAA. The mass was surgically excised and confirmed to be a fibroelastoma on histological examination. This case report describes a rare but treatable source of multiple cerebrovascular events and highlights the utility of TOE in the assessment of cardiac embolic source.

Learning points:

  • Fibroelastomas are most commonly found on left-sided heart valves (aortic > mitral) and have the potential to cause systemic emboli associated with significant morbidity and mortality.

  • A left atrial appendage (LAA) mass in a patient presenting with cerebrovascular events does not always represent thrombus. Uncommon aetiologies such as a cardiac tumour should be considered in the differential diagnosis.

  • Transthoracic echocardiography (TTE) does not provide an accurate assessment of the LAA and should not be used to detect pathology within this structure. Transoesophageal echocardiography (TOE) is superior to TTE in imaging the LAA and provides a complete delineation of its anatomy. In addition, TOE can detect very small highly mobile lesions (as described in this case), which may be missed on other imaging modalities.

Open access

Jet van Zalen, Sveeta Badiani, Lesley M Hart, Andrew J Marshall, Louisa Beale, Gary Brickley, Sanjeev Bhattacharyya, Nikhil R Patel and Guy W Lloyd

Background

Mortality dramatically rises with the onset of symptoms in patients with severe aortic stenosis (AS). Surgery is indicated when symptoms become apparent or when there is ventricular decompensation. Cardiopulmonary exercise testing (CPET) in combination with exercise echocardiography can unmask symptoms and provides valuable information regarding contractile reserve. The aim of the present study was to determine the prevalence of reduced exercise tolerance and the parameters predicting adverse cardiovascular events.

Methods

Thirty-two patients with asymptomatic severe AS were included in this study. Patients were followed up as part of an enhanced surveillance clinic.

Results

Age was 69 ± 15.7 years, 75% of patients were male. Patients had a raised NT-ProBNP of 301 pg/mL. VO2peak was 19.5 ± 6.2 mL/kg/min. Forty-one percent of patients had a reduced %VO2peak and this predicted unplanned cardiac hospitalisation (P = 0.005). Exercise systolic longitudinal velocity (S′) and age were the strongest independent predictors for VO2peak (R 2 = 0.76; P < 0.0001). Exercise S′ was the strongest independent predictor for NT-ProBNP (R 2 = 0.48; P = 0.001).

Conclusion

A large proportion of patients had a lower than predicted VO2peak. The major determinant of exercise and NT-ProBNP is the ability of the left ventricle (LV) to augment S′ on exercise rather than the severity of aortic valve obstruction or resting structural remodelling of the LV. Reduced exercise tolerance and more adverse remodelling, rather than valve obstruction predicted unplanned hospitalisation. This study demonstrates that for those patients, in whom a watchful waiting is an agreed strategy, a detailed assessment should be undertaken including CPET, exercise echocardiography and biomarkers to ensure those with exercise limitation and risk of decompensation are detected early and treated appropriately.

Open access

Josef Finsterer and Claudia Stöllberger