Report from the Annual Conference of the British Society of Echocardiography, November 2017, Edinburgh International Conference Centre, Edinburgh

Vishal Sharma1, Martin Stout PhD MSc BSc2, Keith Pearce BSc2, Allan L Klein MD FRCP(C) FACC FAHA FESC3, Maryam Alsharqi MSc4,5, Petros Nihoyannopoulos MD FRCP FESC FACC FAHA4, Jamal Nasir Khan MBChB PhD BMedSci MRCP6, Timothy Griffiths BA BSc PGDip Card7, Kully Sandhu DM MRCP7, Sinead Cabezon MBChB7, Chun Shing Kwok MBBS MSc BSc MRCP7, Shanat Baig MBBS MRCP7, Tamara Naneishvili MBBS MRCP7, Vetton Chee Kay Lee MBChB7, Arron Pasricha MBChB7, Emily Robins MBChB7, Prathap Kanagala MBBS PhD MRCP8, Tamseel Fatima MBBS MRCP7, Andreea Mihai MBBS MRCP7, Robert Butler MBChB MD FRCP FACC7, Simon Duckett MBBS MD BSc MRCP7, Grant Heatlie MBBS PhD BSc MRCP7, Haotian Gu PhD9, Phil Chowienczyk FRCP9, Linda Arnold10, Sean Coffey11,12, Margaret Loudon MBCHB MRCP DPhil10, Jo Wilson10, Andrew Kennedy10, Saul G Myerson MD FRCP FESC10, Bernard Prendergast13, Alice M Jackson MBChB MRCP14, Vera Lennie MD FESC FRCPEdin15, Peter Lee Luke MSc BSc16, Christopher James Eggett PhD BSc17, Loakim Spyridopoulos MD18, Timothy Simon Irvine MBChB FRCP16, Nashwah Ismail19, Anita Macnab MBChB FRCP19, Caroline Bleakley MB BCh BAO MRCP MD20, Mehdi Eskandari MD FRACP20, Omar Aldalati20, Almira Whittaker20, Marilou Huang20, Mark J Monaghan PhD FRCP FESC FBSE FACC20, Thomas J Turner19, Conor Steele19, Anna Barton21, Alan C Cameron BSc MBChB PhD29, Piotr Sonecki21, Gyee Vuei Phang MBChB MRCP22, Christos Voukalis MD MRCP22, Hwee Phen Teh MBChB22, Stavros Apostolakis MD PhD22, Chih Wong MRCP MD23, Matthew M Y Lee MBChB MRCP23,24, Nicolas E R Goodfield MBChB22, Emma Lane BSc25, David Slessor MBBS FRCEM FFICM25, Richard Crawley BSc BMBS FRCP25, Theodoros Ntoskas MD26, Farhanda Ahmad PgDMU26, Paul Woodmansey MD FRCP26, Andrew J Fletcher MSc27, Shaun Robinson MSc27, Bushra S Rana MBBS FRCP27, Liam Batchelor BSc MSc27, Brogan McAdam28, Caroline J Coats28, Louise C Mayall BSc MRes MSc2, Niall G Campbell PhD MRCP2 and Hannah Garnett PhD MSc BSc29

The 2017 Annual Conference of the British Society of Echocardiography (BSE) was held in Edinburgh on the 10th and 11th November. This was an extremely wellsupported conference with 751 delegates attending. We were delighted to offer an extremely high-quality educational programme. A particular highlight was the final session, which included the current presidents of the three major echocardiography societies in the world. Our own President, Mr Keith Pearce was joined by the President of the American Society of Echocardiography, Prof. Allan Klein and the President of the European Association of Cardiovascular Imaging, Prof. Bogdan Popescu.
This year's BSE International Lecture was given by Prof. Klein, who gave a thorough overview of pericardial diseases and how to assess them with echo. The BSE Invited Lecture was delivered by Prof. John Simpson in which he gave us a glimpse into the future of echocardiography with his talk entitled 'Frontiers in Congenital Heart Disease Imaging'. Prof. Bogdan Popescu also delivered an excellent talk on the assessment of atrial function as part of a dedicated session on the assessment of the left atrium.
For the first time the BSE also included a dedicated session devoted to patients. In the 'My Echo' session, patients gave their own unique perspectives of how their conditions have affected them and how echocardiography had directly impacted their lives. In one particularly memorable anecdote, one of the patients recounted how they had been admitted to hospital with significant breathlessness. Despite being treated for days for a chest infection, their condition steadily worsened and there were real concerns that they would not survive. They then described being taken into a darkened room for an 'ultrasound scan' that was undertaken by a cardiac physiologist. From that point on, the patient recounted that the course of their treatment and ultimately their life changed completely. Following the echo, their severe heart failure was diagnosed, they were moved to a cardiology ward, commenced on appropriate treatment and began to feel better. Their condition improved dramatically and over the next few weeks made an almost complete recovery. This important anecdote not only highlighted the impact that echocardiography has on patients but the importance of ensuring that it can be provided rapidly in all hospitals across the country.
A key theme for this conference was echocardiography in congenital heart disease and there was a dedicated congenital track running throughout the programme. Topics included detailed sessions on the sequential analysis of congenital heart disease with echocardiography, atrial and ventricular septal defects, right and left obstructive lesions and Tetralogy of Fallot. A particular highlight was the session on the assessment of atrial septal defect closure by Alex Savis and as a consequence we invited her and Prof. John Simpson to write a review on the topic for Echo Research and Practice (1).
We were also delighted to hear about the high-quality research that is happening across the United Kingdom at the conference and we have included the abstracts that were presented at the conference in this report.
As always we are grateful to all of our sponsors and industry partners without whom, the annual conference would not be possible.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector. Pericardial diseases involve diseases of the sac that surrounds the heart. Compared to other cardiac diseases, there has been little interest in pericarditis since it has little effect on mortality. However, pericarditis can be associated with significant morbidity which has raised the interest in this field. In 2017, the new term 'complicated pericarditis' describes patients who have multiple recurrent episodes as well as constrictive pericarditis. Imaging modalities such as echo-Doppler, strain imaging and CMR/CT can help establish the diagnosis, prognosticate the severity as well as inform treatment. The pericardium is composed of a serous layer including the visceral (epicardium) and parietal component as well as a fibrous layer. Viruses, uraemia, neoplasm and radiation can all damage the pericardial sac. Initially, there will be fibrinous exudates followed by neutrophil infiltration, neovascularization and then fibrosis. CMR with late gadolinium enhancement (LGE) has become an imaging biomarker of pericardial inflammation. Interestingly, LGE seems to relate to neovascularization of the pericardium and relates to the severity of the inflammation which portends a bad prognosis for having multiple recurrences and likely starting DMARDS and biologics.
Pericardial syndromes include acute, recurrent, incessant and chronic pericarditis, pericardial effusions/ tamponade, constrictive pericarditis and effusive constrictive pericarditis, pericardial masses, cysts and congenital absence of the pericardium. Recent ASE and ESC guidelines have defined how these conditions are diagnosed clinically. Ancillary signs such as elevated inflammatory markers (WSR and CRP) and pericardial inflammation on advanced imaging may help with the diagnosis. It is estimated that 15-30% of patients with acute pericarditis will develop recurrent episodes of which 6% may show multiple recurrences while some will develop transient constrictive pericarditis (treated with anti-inflammatories) and some will develop calcific constrictive pericarditis. The aetiology of pericarditis is different depending whether in the Western world (viral or idiopathic) or developing world (TB). An emerging cause of pericarditis is traumatic or iatrogenic (perforation or delayed onset).
Multimodality imaging plays an integral part in the diagnosis and treatment of pericardial diseases. Echo is usually the first-line test followed by CMR/CT which are second line which are recommended in patients with technically poor echoes, assessing inflammation or evaluating calcium in the setting of previous open heart surgery. Recognition of the different stages of pericarditis from single recurrence to advanced constriction will inform when to use echo, strain imaging, CMR and CT. Recent understanding of the pathophysiology of recurrent pericarditis suggests that there is activation of the 'inflammasome' of the cell, which may cause release of inflammatory biomarkers markers such as interleukins. This may be especially important due to the use of newer targeted therapies such as Il1 alpha and beta receptor blockers.
In conclusion, assessment of pericardial diseases using an imaging-guided approach is responsible for the new renaissance in pericardial diseases.

Declaration of interest
The author declares that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Aims
To evaluate the relation between left ventricular (LV) twist mechanics and left atrial (LA) phasic function in patients with systemic hypertension using speckle tracking echocardiography (STE). We hypothesised that the impairment of LA function is directly related to the reduction in LV untwisting rate (UTR) in hypertensive patients with preserved LV ejection fraction (EF).

Methods
In this prospective study, 74 hypertensive patients (54.17 ± 16.37 years) with preserved EF (65.7 ± 7.29%) were enrolled and compared with 20 normotensive controls. Basal and apical parasternal short axis views were used to assess LV twist mechanics, and apical four-and twochamber views were used to evaluate LA phasic function. Using EchoPac GE STE software, LV twist, UTR, and time to peak UTR were measured and LA longitudinal strain was obtained.

Results
Hypertensive patients with preserved LV EF showed reduced early diastolic UTR (P = 0.0001), prolonged time to peak UTR (P < 0.0001), impaired LA reservoir (P < 0.0001) and conduit (P < 0.0001) function when compared with controls. The reduction of LV UTR was positively correlated with the impairment of LA reservoir (r = 0.54, P < 0.0001) and conduit (r = 0.65, P < 0.0001) function.

Conclusion
In hypertensive patients with preserved LV EF (>50%), the impairment of LA reservoir and conduit function was correlated positively with the reduction in LV UTR, and inversely with time to peak UTR. These correlations may contribute toward the impairment of LV relaxation in hypertensive patients. LV twisting and LA strain indices by STE enable early detection of diastolic abnormalities even in the presence of normal findings in conventional 2D echocardiography.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Background
Physiologist-led stress echocardiography (PLSE) services provide potential for expansion of SE services and increased productivity for cardiologists. There is only one published study on PLSE and no studies assessing its accuracy. We sought to assess the feasibility, safety and accuracy of PLSE and CLSE for coronary artery disease (CAD) assessment.

Methods
Retrospective analysis of 898 patients undergoing PLSE or CLSE for CAD assessment using exercise or dobutamine stress over 24 months. Sixteen-segment wall-motion scoring (WMS, WMSI) analysis was performed. Feasibility (stressor, image quality, proportion of completed studies), accuracy (agreement with imaging cardiologist analysis, sensitivity and specificity compared with invasive coronary angiography) and safety (complication rate) were compared for PLSE and CLSE.

Conclusion
To our knowledge, this is the first study of the feasibility, safety and accuracy of PLSE. PLSE performed by welltrained physiologists is feasible and safe in contemporary practice. PLSE and CLSE interpretation of stress echocardiography for CAD agree closely and show similar accuracy compared with invasive angiography.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Background
Impaired shortening-deactivation of cardiac myocytes could sustain myocardial contraction, preserving ejection fraction at the expense of diastolic dysfunction.

Objective
To examine whether an impairment of early systolic ejection is associated with sustained myocardial contraction and diastolic dysfunction.

Methods
The relation between first-phase ejection fraction (EF1), the fraction of left ventricular volume ejected from the start of systole to the time of the first peak in LV pressure (corresponding to the time of maximal ventricular shortening) to duration of myocardial contraction and diastolic function was examined in patients with hypertension (n = 163) and varying degrees of diastolic dysfunction. LV systolic pressure was estimated by carotid tonometry; time-resolved LV cavity and wall volume were obtained by echocardiography with speckle wall-tracking. Measurements were repeated after nitroglycerin, a drug known to influence ventricular dynamics, in a sub-sample (n = 18) of patients.

Results
EF1 and time of onset of ventricular relaxation (TOR, as determined from the temporal pattern of myocardial wall stress) were strongly correlated (standardized regression coefficients -0.34 and 0.34 respectively, each P < 0.001) with diastolic function as measured by the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/E′) irrespective of adjustment for age, sex, antihypertensive treatment, measures of afterload and ventricular geometry. Nitroglycerin increased EF1, decreased TOR and improved diastolic function (each P < 0.05) ( Fig. 1 and Table 1).

Conclusion
Hypertensive patients with diastolic dysfunction exhibit reduced first-phase ejection fraction which may sustain myocardial contraction, preserving systolic ejection fraction at the expense of impaired diastolic function.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Received in final form 21 October 2019 Accepted 21 October 2019
arPWV, aortic root pulse wave velocity; AV, aortic valve; BMI, body mass index; bmp, beats per minute; DBP, diastolic blood pressure; E/E′, ratio of mitral valve Doppler early flow (E wave velocity) to tissue Doppler mitral annulus movement (E′ wave velocity); EDV, end-diastolic volume; EF1, first-phase ejection fraction; HR, heart rate; LA, left atrium; LVMI, left ventricular mass index; MWS ED/ES, ratio of end-diastolic and end-systolic myocardial wall stress; SBP, systolic blood pressure; T1, time to first systolic peak on pressure waveform; TOR, time to onset of relaxation.

Background
Aortic sclerosis (ASc) is a frequent incidental finding during echocardiographic examination. ASc is associated with, and may be an independent risk factor for, the development of cardiovascular (CV) events.

Purpose
To determine whether the increased CV risk associated with ASc was predicted by standard risk stratification using the QRISK2 CV risk assessment tool (prediction of 10-year CV event rate) in a cohort of patients over the age of 65 years.

Methods
We evaluated subsets of participants (total n = 201: 135 with ASc; 66 controls) recruited to a population valve disease screening study (OxVALVE Study) using a nested, quantitative case-control study approach. The QRISK2 10-year risk score was calculated and analysed according to echocardiographic results. Data concerning patient medication were also collected.

Results
The average QRISK2 score was significantly higher in the ASc group compared to the non-ASc group (30.1 vs 23.8%, P = 0.0006). The ASc group was older by just under 3 years (72.5 years vs 69.6 years, P = 0.0001). Total cholesterol and HDL/cholesterol ratios were similar in the two groups. There was a non-significant trend towards higher systolic blood pressure (155 mmHg vs 150 mmHg, P = 0.068) and diabetes in the ASc group (12.6 vs 6.1%, P = 0.22). The study was not powered to determine whether ASc was an independent risk factor for cardiovascular disease. Of patients (n = 143) with a QRISK of >20%, only 56% were on statins, 34% on aspirin and 28% on ACE inhibitors.

Conclusion
We have confirmed that ASc is a marker for higher cardiovascular risk as assessed by the QRISK2 score. Therefore, the incidental finding of ASc should serve as a prompt to reassess cardiovascular risk and echocardiography reports could highlight this finding. Many patients with high cardiovascular risk in our study were not on appropriate primary prevention medication.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
The OxVALVE study is funded by the NIHR Oxford Biomedical Research Centre.

Introduction
It is well known that up to half of patients hospitalised for heart failure have a normal left ventricular ejection fraction (LVEF). Identifying raised LV filling pressures (LVFP) in this cohort is important to guide management. Data regarding the use of NT-proBNP in this setting, and its correlation with diastolic dysfunction, are lacking.

Aims
• Describe the relationship between NT-proBNP and LVFP. • Identify the proportion of patients with raised NT-proBNP but normal LVEF and LVFP. • Examine the correlation between NT-proBNP and markers of LV systolic and diastolic function, including global longitudinal peak systolic strain (GLPSS).

Methods
We performed a retrospective analysis of all patients referred to our open access heart failure service over 9 months. For those with NT-proBNP >300 ng/L, we collected echocardiographic measurements of LV systolic and diastolic function, and valvular disease. Contemporary ASE/EACVI recommendations were used to estimate LVFP. GLPSS was calculated using speckle tracking (GE software).

Results
A total of 172 NT-proBNP measurements were performed during the study period. Forty-eight (28%) patients had levels >300 ng/L. Baseline characteristics are shown in Table 2. LVFP was raised in 38%. 72% of patients with raised LVFP had NT-proBNP levels >900 ng/L and 6% had NT-proBNP levels of 300-450 ng/L (Fig. 2). A third of the cohort had normal LVEF and LVFP. Of these, 31% (n = 5) had atrial fibrillation (AF). 23% (n = 11) of patients had no evidence of reduced LVEF, raised LVFP, or AF. Figure 3 shows the correlation of NT proBNP with markers of LV systolic and diastolic function, including GLPSS.

Conclusion
Our study demonstrates a clear association between NT-proBNP level and LVFP. This becomes more robust as the level increases >900 ng/L. Left atrial volume appears to correlate with NT-proBNP and is of value in routine assessment of patients with breathlessness. Few patients with raised LVFP had NT-proBNP levels <450 ng/L. There remains debate surrounding the optimal cut-off value. Degree of NT-proBNP elevation according to LV filling pressure.

Figure 3
Correlation of NT-proBNP with markers of LV systolic and diastolic function.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Introduction
The echocardiographic assessment of left ventricular diastolic function (LVDF) remains challenging. At present there are two recognised guidelines provided by the British Society of Echocardiography (BSE) and American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI). However, to date, no direct comparison of these guidelines has been performed to establish whether they provide similar diastolic grading.

Methods
Three hundred and thirty-three patients in sinus rhythm were extracted from our echo database (McKesson Cardiology). Eighty-seven (26%) patients were excluded due to left bundle branch block (2.1%), no indexed left atrial volume (18.2%) and annular calcification (5.7%). For each patient, LVDF assessment was performed using both guidelines and the results compared. Chi-square, Spearman correlation and Kappa score statistical tests were used to evaluate the data at a level of P < 0.05.

Results
The most frequent outcome was unclassifiable LVDF with significantly more patients being labelled unclassified by BSE (ASE/EACVI 31.3% vs BSE 39.5%, P < 0.0001). Having excluded unclassifiable patients, no difference was observed between the two schemes (P = 0.422) with substantial agreement when differentiating between normal and abnormal diastolic function (k = 0.694, P < 0.0001). Where there was disagreement between the two guidelines, (i.e. normal LVDF by one and abnormal by the other), the degree of LVDF was never more than grade I. When grading subcategories were individually compared there was moderate agreement between the two guidelines (k = 0.581, P < 0.0001). A significant correlation was seen between LV impairment (r = 0.55, P < 0.0001), indexed LA volume (r = 0.41, P < 0.001) and E/e′ (r = 0.68, P < 0.0001) with both diastolic grading schemes.

Conclusion
In around one-third of patients it was not possible to grade LVDF by either guideline. For those patients where grading was possible, there was no significant difference between BSE and ASE/EACVI guidelines with substantial agreement between each scheme when diagnosing normal or abnormal diastolic function and moderate agreement when comparing each LVDF subcategory.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

N Ismail and A Macnab
Safety of stress echocardiography

Background
Stress echocardiography (SE) is a widely used diagnostic tool for ischaemic heart disease. However, this type of functional testing has inherent risks and there is limited contemporary data on complication rates. We therefore carried out an audit of complications in a high-volume UK stress echo laboratory.

Methods
This was a retrospective audit of all SEs carried out in our center over 8 years between 2009 and 2017. Both dobutamine SE (DSE) and exercise SE (ESE) were included. The DSE protocol used a maximum dose of 30 µg/kg/min of dobutamine with atropine and handgrip augmentation as required. For ESEs the Bruce protocol was used on the treadmill and the WHO25 protocol on the semi-supine bicycle. Trans-pulmonary contrast was used in 95% of patients having DSE and 70% of patients having ESE. All complications were recorded even if no therapeutic intervention was required by the operator other than termination of the test.

Conclusion
Stress echo is a safe functional imaging test. ESE results in significantly fewer complications than DSE. Contrast reactions occur more frequently than that reported by the manufacturers.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Background
In mitral stenosis (MS), measuring the mitral valve orifice area (MVOA) by 3D transthoracic echocardiography (TTE) offers an adjustable dataset that can be manipulated to more accurately align with the true MVOA in comparison to 2D TTE. We studied differences in MVOA measurements between 2D and 3D methods, to determine if 3D echocardiography would result in the re-grading of severity in any cases.

Methods
This was a head-to-head comparison of the three most commonly used tools to grade mitral stenosis by orifice area. 3D measurements of the MVOA were performed prospectively in 42 consecutive patients with at least mild mitral stenosis (MS) by traditional 2D estimates (pressure half-time (PHT), 2D MVO). The 2D MVOA was measured by the operator who performed the TTE, the 3D MVOA was measured separately by a blinded operator.

Conclusion
3D planimetry of the MVOA returns significantly smaller measurements, which in some cases results in the reclassification of the grade of stenosis. Routine use of 3D measurements may have significant impact on the management of patients with MS by suggesting an increased severity of disease.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

T J Turner et al.
Adverse event rates after normal SE discharge

Aims
It is known that a normal stress echocardiogram (SE) carries a very high negative predictive value (NPV). We sought to determine the prognostic value of a negative SE when investigating patients for suspected angina in the setting of a contemporary rapid access chest pain clinic.

Methods
Between 2013 and 2015, patients who were investigated with SE were identified from the clinic records. The type of SE the patient underwent, exercise (ESE) or dobutamine (DSE), was also recorded. Only those with normal resting echo and normal SE were followed up with a telephone survey in 2017. Major adverse cardiac events (MACE) in the 2 years post discharge were recorded. Medical records were searched for all hospital admissions and deaths.

Results
In the 2-year study period, 1815 patients attended the clinic. Of these, 802 were investigated with SE, with 446 receiving a negative result. Out of these, 95 were not contactable, which left 351 patients (DSE = 147 vs ESE = 204) with follow-up data. Pre-test probability of angina was low in 171 (49%), medium in 102 (29%) and high in 78 (22%) patients. Death occurred in nine patients, with only one being attributed to a cardiac cause. Overall, four MACE occurred (three events requiring revascularisation and one cardiac death). The MACE rate was 1 (0.28%) in the first year and 3 (0.85%) for the second year post discharge. The 2-year NPV for cardiac events was 98.86%. There was no significant difference between patients who received DSE and ESE (1 event (0.7%) in DSE group vs 3 events (1.5%) in ESE group; P = 0.493).

Conclusion
Negative SE in patients confers a high NPV and thus indicates an excellent prognosis, even in a population with a high proportion of patients (51%) with a medium or high pre-test probability of angina.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Introduction
An echocardiogram result can be reviewed in several ways. Locally, a report is generated featuring detailed results and a summary report. Images are also available to review, predominantly in the hospital setting. We investigated how different staff groups reviewed the echocardiograms they had requested.

Methods
A survey concerning echocardiogram requests, and resultreviewing behavior was circulated via email to medical and specialist nursing staff in Glasgow. All levels of medical, surgical, radiology, OBGYN, paediatric and GP trainees, and staff grades, GPs, consultants, and nurse specialists were included, totaling 2218 hospital staff and 266 GP practices. Responses were collected from 15/7/16 to 2/8/16.

Results
Cardiologists (n = 16) were compared against hospital noncardiology (n = 126) and GP staff (n = 122). Cardiologists requested 41.4 echocardiograms/practitioner/month, compared to 6.5 for hospital non-cardiology staff, and 1.3 for GPs. 100% of cardiologists always reviewed a summary report, compared to 94% of hospital noncardiology staff and 93% of GPs, compared to 80%, 58% and 31% respectively for the detailed report, and 33%, 8% and 1% for images. No cardiologists described never reviewing any results, compared to 4% of hospital noncardiology staff and 2% of GPs.

Conclusion
Almost all respondents review at least one aspect of an echo report; however, most review the summary report alone. Cardiologists request the most scans and are most likely to review all aspects of the report. GPs request the least and are least likely to review a detailed report. Noncardiology staff request the greatest proportion of all echocardiograms, and review a detailed report in >50% of cases. Non-cardiologists are unlikely to review images. It is reasonable for non-specialists not to review more detailed aspects of an echocardiogram; this emphasizes the need for any vital messages to be communicated to the referrer through the summary report to optimize the chance of being reviewed.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Aim
To assess whether stress echocardiography (SE) is safe and has satisfactory detection rate of ischaemia.

Methods
We performed a retrospective study of a total of 426 patients who had SE within a period of 12 months (February 2015 to January 2016) for assessment of ischaemia. All patients were followed up for a mean period of 20 months. Collected data included mode of stressors, complications, management of the positive SE results and readmission of patients with chest pain with their subsequent management plan.

Results
418 individuals completed the test and 8 tests were inconclusive. 78.9% had treadmill and 21.1% had dobutamine infusion as stressors. 99% of patients had no complications post-test; one patient suffered ventricular tachycardia, one patient had non-ST elevation myocardial infarction, three patients experienced troponin-negative chest pain and one patient suffered from contrast allergy. No deaths were reported.
12.7% (55) had positive SE and 83.6% (363) had negative SE (Table 3). Of the 55 patients who had positive SE outcome, 51 patients underwent coronary angiogram and 56.5% (31) of them were diagnosed with flow-limiting coronary artery disease. Nineteen were managed with percutaneous coronary angioplasty, eight with coronary artery bypass graft and four conservatively (Table 4).
6.1% (22) of the negative SE group had readmission with chest pain and/or acute coronary syndrome and underwent coronary angiogram, but only eight patients required revascularisation. There was no significant statistical difference between the dobutamine vs treadmill for detection of the negative SE. In contrast, for the detection of true positives, dobutamine was superior to exercise (P value, 0.009).
From the results, SE in our department has a sensitivity of 80%, specificity of 95%, positive predictive value of

Conclusion
SE is a safe imaging modality with very low complication rate and is also efficient with an outstanding negative predictive value.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Background
The guidelines of the American Society of Echocardiography (ASE) on the assessment of the right heart recommends that fundamental imaging should be used to measure right ventricular (RV) free wall thickness when image quality permits to 'avoid the increased structure thickness seen with secondary harmonic imaging'. However, no reference is provided. We could not find any data comparing RV free wall thickness measured by echocardiography vs. cardiac magnetic resonance imaging (CMR). We hypothesized that RV free wall thickness is overestimated by secondary harmonic imaging by echocardiography.

Purpose
To compare RV free wall thickness measured by echocardiography vs CMR.

Methods
Thirty near-consecutive patients who had both echocardiography and CMR performed in our center in the past 6 months were selected. RV free wall thickness was measured independently by C W and N E R G using echocardiography with secondary harmonic imaging; and by C W and M M Y L using CMR. Patients with significant RV hypertrophy (>1.0 cm) were excluded. The results were compared using the Bland-Altman Plot to measure agreement between them.

Results
Among the 30 patients, the mean difference between echocardiography and CMR was 0.29 cm (standard deviation 0.11). The mean difference is statistically different from zero suggesting the measurements between echocardiography and CMR do not agree (P < 0.001). Figure 5 illustrates the results using the Bland-Altman Plot showing the mean difference of 0.29 cm (red line) with 95% confidence interval of 0.07 to 0.50 cm (green lines). This confirms the lack of agreement between echocardiography and CMR, with discrepancies of up to 0.50 cm by echocardiography. This discrepancy is too large to accurately measure the RV free wall with a normal reference range of ≤0.5 cm.

Conclusion
Compared to CMR, RV free wall thickness is overestimated by echocardiography using secondary harmonic imaging. Fundamental imaging (as per ASE guidelines) should be used to measure RV free wall thickness.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Background
Sepsis-induced cardiomyopathy occurs in up to 14% of patients with sepsis, resulting in myocardial depression typically resolving after 7-10 days. Transthoracic echocardiographic (TTE) assessment of left ventricular ejection fraction (LVEF) is typically used to define sepsis-induced cardiomyopathy. Recent meta-analysis demonstrates that low LVEF was not associated with mortality in septic patients. Advanced echocardiographic techniques such as global longitudinal strain (GLS) have evolved for direct assessment of the myocardial function. This technique may be beneficial for the assessment of sepsis-induced cardiomyopathy.

Primary objective
In critically ill patients with sepsis and septic shock, does GLS compared with LVEF identify more patients with myocardial dysfunction?

Methods
Over a 4-month period, GLS and LVEF were performed retrospectively from standard study imaging, on patients admitted to the Intensive Care Unit with sepsis, as defined by Sepsis-3 Criteria. All images were performed on GE S70 machines by a British Society Echocardiography accredited sonographer.

Results
Thirteen patients met the inclusion criteria and had adequate imaging to measure LVEF and GLS. Three patients had a reduced LVEF, whereas nine patients had a reduced GLS. This was a statistically significant difference (P = 0.047). Of the four patients who had a preserved LVEF and normal GLS, one patient was on inotropes and one patient had cirrhosis which is associated with a hyperdynamic circulation.

Conclusion
Critically ill patients with sepsis were statistically significantly more likely to have low GLS compared with reduced LVEF. These data suggest that GLS in standard TTE could have value in the septic patient for early detection of LV dysfunction. With the use of advanced techniques, septic-induced cardiomyopathy may be more commonly diagnosed. It may help identify patients who are critically ill from sepsis and target treatment accordingly. Future studies should investigate whether a reduced GLS is associated with mortality.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector. The DSE service has traditionally been a consultant cardiologist led service. However, with increasing demand, the expansion of DSE indications and to cut waiting times, a cardiac physiologist managed DSE service is running in our tertiary hospital. We audited the reason for the study, complications, safety and reliability, and validity of physiologist-led DSE services.

Methods
Retrospective analysis of 333 patients undergoing stress echocardiography for inducible reversible ischemia, myocardial viability and valvular heart disease (VHD) over 6 months. Patients' case notes review after 18-24 months.

Results
92% of all cases (306) were performed by physiologists. In 305 studies dobutamine was used ( Table 5). The overwhelming majority of the referrals were for coronary artery disease (CAD) assessment (285). In 238 cases the study was uncomplicated. 67 patients developed dobutamine-related side effects including arrhythmias, nausea, vomiting, dizziness, vasovagal episodes, chest pain and shortness of breath (Table 6). In only 16 out of 67 cases did the complications listed above lead to early termination of the study (Table 7). In two cases, urgent review from the on-call cardiologist registrar was needed because of severe vasovagal reactions. Of the 285 studies for CAD assessment, 244 were negative for ischemia, 28 were positive and 13 inconclusive (Table 8). Only 7 cases with negative DSE for ischemia were readmitted as an ACS or for unstable angina; in these cases an invasive coronary angiogram (CA) or another non-invasive functional test revealed CAD (a false-negative rate for CAD of 2.9%). 5 out of 28 cases, with echocardiogram

Conclusion
In our hospital, the majority of DSE lists are led by physiologists. The above results demonstrate the reliability and safety of this practice, and provide potential for the expansion of physiologist led DSE services in other hospitals.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Background
Inferior vena cava (IVC) size and collapsibility upon inspiration, plus right atrial (RA) size, are commonly assessed during transthoracic echocardiography and are recommended to guide estimation of right atrial pressure (RAP). The ratio of right ventricular (RV) early diastolic filling velocity (E) to early diastolic tricuspid annular tissue velocity (e′), called RV-E/e′, is a surrogate of RV filling pressure and is another echocardiographic parameter which can be used to estimate RAP. Studies of RV-E/e′ suggest that it is strongly and positively correlated with invasively measured RAP, but less is known about its relationship with other echocardiographic parameters used to estimate RAP.

Aim
We sought to determine whether RV-E/e′ is correlated with IVC size, IVC collapsibility upon inspiration or with RA size when assessed with transthoracic echocardiography.

Methods
Data were collected retrospectively in consecutive patients in whom RV E velocity, RV e′ velocity, RA volume indexed to body surface area, IVC size and IVC collapsibility were assessed using transthoracic echocardiography (inclusion criteria). Patients with inter-atrial/ventricular communication, previous heart transplantation or at least moderate tricuspid/pulmonary regurgitation (TR/PR) were excluded. Images were obtained using Philips IE33 ultrasound machines by British Society of Echocardiography accredited cardiac physiologists as part of routine clinical service. Statistical analysis of normality and correlation were undertaken using SPSS. Significance was assumed for P < 0.05.

Results
Data from 138 patients was collected. Three patients were excluded due to inter-atrial communication, 7 for previous heart transplantation and 25 for at least moderate TR/PR. Hence 103 patient's data were analysed. Demographic and clinical details are presented in Table 9. RV-E/e′ was not statistically significantly correlated with IVC size (r = −0.17, P = 0.088), IVC collapsibility (r = −0.06, P = 0.524) or with RA size (r = −0.13, P = 0.202).

Conclusion
RV-E/e′ does not correlate with other echocardiographic parameters commonly used to estimate RAP in patients with a variety of pathologies.

Introduction
Pulmonary endarterectomy (PEA) is a potentially curative procedure for chronic thromboembolic pulmonary hypertension (CTEPH). Currently, little echocardiographic data exists regarding anatomical and functional remodelling of the right ventricle (RV) post-PEA, and whether pre-surgical haemodynamics influence recovery.

Methods
Forty patients (n = 40) who underwent PEA surgery for CTEPH were retrospectively sampled in a reverse chronological methodology. Patients underwent transthoracic echocardiography pre-surgery, and 3 and 12 months post surgery. Patients were categorised according to the presence (PH+) or absence (PH−) of PH post surgery (Tables 10 and 11).

Figure 7
RV S′ measures in PH− and PH+ groups pre-and post-surgery. § Sig dif compared to pre-surgery (P < 0.05).

Conclusion
This study suggests longitudinal function remains reduced one-year post-PEA regardless of post-surgical PH status, with gradual PH recovery of radial function. Although both groups EDA and ESA reduced significantly within three-months, only PH ESA reductions from pre-surgery were sustained at 12 months. Future research should establish whether anatomical and functional differences post-PEA are associated with symptomatic outcomes.
L C Mayall et al.

Background
There is increasing evidence to suggest that long-term right ventricular (RV) apical pacing is associated with adverse outcomes such as progressive left ventricular (LV) dysfunction, heart failure and a significantly increased risk of mortality. The NICE TA314 guidance recommends the implantation of cardiac resynchronisation therapy (CRT) for patients with LV systolic dysfunction and an associated LV ejection fraction of 35% or less in order to restore electrical and mechanical synchrony.

Aims
• To identify the percentage of RV-paced patients who are eligible for an upgrade to CRT based on the NICE TA314 guidance. • To determine whether patients with high percentages of RV apical pacing were more likely to be eligible for an upgrade to CRT.

Methods
Patients who were attending pacemaker outpatient clinics underwent a pacemaker check, a resting 12-lead electrocardiogram, a symptom assessment and a transthoracic echocardiogram in order to assess their eligibility for an upgrade to CRT.

Results
There was no significant difference between the percentage of patients who were eligible for an upgrade in the <40% paced and the ≥40% paced groups (n = 45). 18% of patients were eligible for a device upgrade.

Conclusion
This study has identified patients who meet the NICE TA314 eligibility criteria, thus allowing the NHS to focus its resources where they will achieve the greatest benefit.

Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
H Garnett et al.
The effects of hand-grip exercise on cardiac function

Background
Bike stress echocardiography (BSE) is routinely used as a non-invasive test for functional myocardial ischaemia in patients experiencing angina-like chest pain. Myocardial ischaemia is diagnosed when reduced coronary blood flow results in regional wall motion abnormalities, which can be quantified using strain analysis. In current practice, patients are asked to perform a hand-grip exercise when leg fatigue develops to help ensure they reach their target heart rate (THR).

Aims
This study aimed to identify whether there is a difference in cardiac workload or duration of a satisfactory test, following isotonic bike exercise and isometric hand-grip exercise (IHGE) in combination, compared to isotonic bike exercise alone in healthy adults.

Methods
A repeated-measures design was used in which healthy adult volunteers were exercised to 85% of their THR using isotonic bike exercise alone in one session and isotonic bike exercise in combination with an IHGE in another session. Echocardiographic images and blood pressure were recorded throughout exercise and recovery. Systolic global longitudinal strain (GLS) and ejection fraction (EF) were calculated from echocardiogram images to assess cardiac workload and volumes.

Results
There was no significant difference in the response of GLS (n = 20) or EF (n = 24) to isotonic bike exercise alone when compared to isotonic exercise with an IHGE. There was also no significant change in the time taken to reach peak exercise, or to recover to a heart rate <100 bpm between the two exercise protocols (n = 20).