The 34th annual Advances in Contrast Ultrasound (ACU) International Bubble Conference convened in Chicago, IL, USA, on September 5–6, 2019 to feature new directions of research, preclinical and first-in-man clinical trials, and novel clinical applications highlighting the diversity and utility of contrast enhanced ultrasound (CEUS). An expert group comprising clinicians, engineers, basic scientists, government officials, attorneys, and industry partners convened to collaborate on cutting-edge ultrasound enhancement technology. Utilizing this information, the International Contrast Ultrasound Society (ICUS) continues to have cause to advocate for the safe and appropriate use of CEUS with expanding indications and applications.
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Stella Kyung, Alan Goldberg, Steven Feinstein, Stephanie Wilson, Sharon Mulvagh and Petros Nihoyannopoulos
Patrick Savage and Michael Connolly
Mitral valve repair is the gold standard treatment for degenerative mitral valve disease with superior perioperative and long-term morbidity and mortality outcomes vs mitral valve replacement. The 10 year survival freedom from redo valve repair varies from 72 to 90%. Often, failure of valve repair necessitating redo surgery is directly related to disease progression; however, rarely it can be attributed to technical complications such as annuloplasty dehiscence, leaflet suture rupture, incorrect artificial chord length or incorrect annuloplasty position. We report one such case of severe mitral regurgitation secondary to a degenerative annuloplasty ring suture occurring 1 year post valve repair.
- Differentiation of causative pathology involved in recurrent mitral regurgitation following repair has important implications for patient outcomes.
- In the hands of an experienced practitioner echocardiography – in particular, integrated 2D- and 3D echocardiography – is a powerful tool for differentiating between progressive disease and procedural failure.
Abbas Zaidi, Daniel S Knight, Daniel X Augustine, Allan Harkness, David Oxborough, Keith Pearce, Liam Ring, Shaun Robinson, Martin Stout, James Willis, Vishal Sharma and the Education Committee of the British Society of Echocardiography
The structure and function of the right side of the heart is influenced by a wide range of physiological and pathological conditions. Quantification of right heart parameters is important in a variety of clinical scenarios including diagnosis, prognostication, and monitoring response to therapy. Although echocardiography remains the first-line imaging investigation for right heart assessment, published guidance is relatively sparse in comparison to that for the left ventricle. This guideline document from the British Society of Echocardiography describes the principles and practical aspects of right heart assessment by echocardiography, including quantification of chamber dimensions and function, as well as assessment of valvular function. While cut-off values for normality are included, a disease-oriented approach is advocated due to the considerable heterogeneity of structural and functional changes seen across the spectrum of diseases affecting the right heart. The complex anatomy of the right ventricle requires special considerations and echocardiographic techniques, which are set out in this document. The clinical relevance of right ventricular diastolic function is introduced, with practical guidance for its assessment. Finally, the relatively novel techniques of three-dimensional right ventricular echocardiography and right ventricular speckle tracking imaging are described. Despite these techniques holding considerable promise, issues relating to reproducibility and inter-vendor variation have limited their clinical utility to date.
Nam Tran, Chun Shing Kwok, Sadie Bennett, Karim Ratib, Grant Heatlie and Thanh Phan
A 62-year-old female was admitted with severe left-sided chest pain, nausea and pre-syncope. She had widespread T wave inversion on ECG and elevated troponins and was suspected to have an acute coronary syndrome event. Invasive coronary angiogram revealed normal coronary anatomy with no flow-limiting lesions. Echocardiography and cardiac MRI revealed impaired left ventricular (LV) systolic impairment, a mobile LV apical thrombus and a moderate global pericardial effusion with no significant compromise. Full blood count analysis indicated the patient to have significant eosinophilia, and the patient was diagnosed with idiopathic eosinophilic myocarditis. She was commenced on Prednisolone and Apixaban, and eosinophil levels returned to normal after 10 days of steroids. Over the course of 3 months, the patient had a complete recovery of her LV function and resolution of the LV thrombus. This case highlights a rare, reversible case of idiopathic eosinophilic myocarditis which may present similar to acute coronary syndrome.
- Eosinophilic myocarditis (EM) is a rare disease that can exhibit symptoms similar to acute coronary syndrome events.
- The diagnosis of EM should be considered in patients with chest pain, normal coronary angiogram and pronounced eosinophilia levels.
- Endomyocardial biopsy is the gold standard diagnostic tool; however, it has a low sensitivity detection rate and its use is not indicated in some patients.
- Echocardiography is useful in the initial detection of cardiac involvement and complications. However, echocardiography lacks diagnostic specificity for all forms of myocarditis including EM.
- Cardiac magnetic resonance is a useful method and may add in diagnosing all forms of myocarditis including EM.
- Patients with EM should be identified promptly and treated with high doses of oral glucocorticoid to reduce the risk of permanent cardiac dysfunction.
Allan Harkness, Liam Ring, Daniel X Augustine, David Oxborough, Shaun Robinson, Vishal Sharma and the Education Committee of the British Society of Echocardiography
This guideline presents reference limits for use in echocardiographic practice, updating previous guidance from the British Society of Echocardiography. The rationale for change is discussed, in addition to how the reference intervals were defined and the current limitations to their use. The importance of interpretation of echocardiographic parameters within the clinical context is explored, as is grading of abnormality. Each of the following echo parameters are discussed and updated in turn: left ventricular linear dimensions and LV mass; left ventricular volumes; left ventricular ejection fraction; left atrial size; right heart parameters; aortic dimensions; and tissue Doppler imaging. There are several important conceptual changes to the assessment of the heart’s structure and function within this guideline. New terminology for left ventricular function and left atrial size are introduced. The British Society of Echocardiography has advocated a new approach to the assessment of the aortic root, the right heart, and clarified the optimal methodology for assessment of LA size. The British Society of Echocardiography has emphasized a preference to use, where feasible, indexed measures over absolute values for any chamber size.
Paul F Clift and Elena Cervi
Aortic diseases may be diagnosed after a long period of subclinical development or they may have an acute presentation. Acute aortic syndrome is often the first sign of the disease, which needs rapid diagnosis and decision making to reduce the extremely poor prognosis. Aortic dilatation is a well-recognised risk factor for acute events and can occur as a result of trauma, infection, or, most commonly, from an intrinsic abnormality in the elastin and collagen components of the aortic wall. Over the years it has become clear that a few monogenic syndromes are strongly associated with aneurysms and often dictate a severe presentation in younger patients while the vast majority have a multifactorial pathogenesis. Conventional cardiovascular risk factors and ageing play an important role. Management strategy is based on prevention consisting of regular follow-up with cross-sectional imaging, chemoprophylaxis of further dilatation with drugs proved to slow down the disease progression and preventative surgery when dimension exceeds internationally recognised cut-off values for aortic diameters and the risk of rupture/dissection is therefore deemed very high.
Sarah Ritzmann, Stephanie Baker, Marcus Peck, Tom E Ingram, Jane Allen, Laura Duffy, Richard P Steeds, Andrew Houghton, Andrew Elkington, Nina Bual, Robert Huggett, Keith Pearce, Stavros Apostolakis and Afshin Khalatabari
This article sets out a summary of standards for departmental accreditation set by the British Society of Echocardiography (BSE) Departmental Accreditation Committee. Full standards are available from www.bsecho.org. The BSE were the first national organisation to establish a quality standards framework for departments that support the practice of individual echocardiographers. This is an updated version which recognises that, not only should all echocardiographers be individually accredited as competent to practice, but that departments also need to be well organised and have the facilities, equipment and processes to ensure the services they deliver are of an appropriate clinical standard. In combination with individual accreditation, departmental accreditation lays down standards to help ensure safe and effective patient care. These standards supersede the 2012 BSE departmental accreditation standards. Standards are set to cover all potential areas of practice, including transthoracic (level 2) echocardiography, transoesophageal echocardiography, stress echocardiography, training and emergency (level 1) echocardiography. The emergency echo standard is a new addition to departmental accreditation and have been developed with input from the Intensive Care Society.
Handi Salim, Martin Been, David Hildick-Smith and Jamal Nasir Khan
A 27-year old intravenous drug user presented to our institution with chest pain. She had a history of bicuspid aortic valve endocarditis with aortic root abscess repaired with bioprosthetic aortic valve replacement and pericardial patch reconstruction of the left ventricular outflow tract and non-coronary sinus 6-weeks previously. Echocardiographic and cardiac CT imaging confirmed 3 foci of breakdown of the pericardial patch repair with active bleeding into a large posterior pseudoaneurysm (92mm diameter) compressing the left atrium and pulmonary artery. Following multidisciplinary discussion, the consensus was to attempt urgent percutaneous closure of the defect given prohibitive surgical risks. The procedure was performed under fluoroscopic and 3D-transoesophageal guidance. TOE demonstrated the pericardial patch breaches and active bleeding into the large pseudoaneurysm. Initial deployment of an Amplatzer Vascular Plug (AVP-2) device resulted in significant flow reduction but there remained two small peri-device leaks. During an attempt to implant an additional smaller Amplatzer device to rectify this, the initial device dislodged and embolised into the pseudoaneurysm. This was felt irretrievable and unlikely to be clinically significant given its containment. The embolised device freely floated within the pseudoaneurysm, uniquely akin to a satellite orbiting in space. The secondary device was removed and initial breach satisfactorily closed with a 15mm-sized Amplatzer atrial septal defect occluder (third device). This was confirmed to be well-seated on real-time 3D imaging with negligible residual leak on TOE. This is the first published case of percutaneous cardiac device embolization into a pseudoaneurysm cavity that we are aware of.
Daniel P Walsh, Kadhiresan R Murugappan, Achikam Oren-Grinberg, Vanessa T Wong, John D Mitchell and Robina Matyal
Interactive online learning tools have revolutionized graduate medical education and can impart echocardiographic image interpretive skills. We created self-paced, interactive online training modules using a repository of echocardiography videos of normal and various degrees of abnormal left ventricles. In this study, we tested the feasibility of this learning tool. Thirteen anesthesia interns took a pre-test and then had three weeks to complete the training modules on their own time before taking a post-test. The average score on the post-test (74.6% ± 11.08%) was higher than the average score on the pre-test (57.7% ± 9.27%) (p < 0.001). Scores did not differ between extreme function (severe dysfunction or hyperdynamic function) and non-extreme function (normal function or mild or moderate dysfunction) questions on both the pre-test (p = 0.278) and post-test (p = 0.093). The interns scored higher on the post-test than the pre-test on both extreme (p = 0.0062) and non-extreme (p = 0.0083) questions. After using an online educational tool that allowed learning on their own time and pace, trainees improved their ability to correctly categorize left ventricular systolic function. Left ventricular systolic function is often a key echocardiographic question that can be difficult to master. The promising performance of this educational resource may lead to more time-efficient, cost-effective methods for improving diagnostic accuracy among learners.