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Open access

A case of isolated bicuspid pulmonary valve

Ramasamy Manivarmane, Rebecca Taylor, and Rajdeep Khattar

Our case highlights the finding of an abnormal pulmonary valve on 2D echocardiography, confirmed to be of bicuspid morphology with 3D imaging. The use of biplane imaging both in transthoracic and transoesophageal echocardiography and routine use of three-dimensional views particularly in transoesophageal echocardiography are of incremental value in better delineating pulmonary valve anatomy.

Learning points:

  • Bicuspid pulmonary valve as an isolated clinical entity is a rare finding in clinical practice with an incidence of about 0.1%.

  • The true prevalence of the condition may be underestimated because of difficulty in visualising the pulmonary valve en-face on standard two-dimensional echocardiography.

  • Trans-oesophageal echocardiography may provide better visualization of the pulmonary valve when transthoracic images are affected by interference from the left lung.

  • Routine use of 3D echocardiography with biplane and zoomed views should be advocated for a full morphological assessment of the pulmonary valve, whether imaging via the transthoracic or transoesophageal approach.

Open access

Transthoracic echocardiography of hypertrophic cardiomyopathy in adults: a practical guideline from the British Society of Echocardiography

Lauren Turvey, Daniel X Augustine, Shaun Robinson, David Oxborough, Martin Stout, Nicola Smith, Allan Harkness, Lynne Williams, Richard P Steeds, and William Bradlow

Hypertrophic cardiomyopathy (HCM) is common, inherited and characterised by unexplained thickening of the myocardium. The British Society of Echocardiography (BSE) has recently published a minimum dataset for transthoracic echocardiography detailing the core views needed for a standard echocardiogram. For patients with confirmed or suspected HCM, additional views and measurements are necessary. This guideline, therefore, supplements the minimum dataset and describes a tailored, stepwise approach to the echocardiographic examination, and echocardiography’s position in the diagnostic pathway, before advising on the imaging of disease complications and invasive treatments.

Open access

The echocardiography of replacement heart valves

John B Chambers

This is a practical description of how replacement valves are assessed using echocardiography. Normal transthoracic appearances including normal variants are described. The problem of differentiating normal function, patient–prosthesis mismatch and pathological obstruction in aortic replacement valves with high gradients is discussed. Obstruction and abnormal regurgitation is described for valves in the aortic, mitral and right-sided positions and when to use echocardiography in suspected infective endocarditis. The roles of transoesophageal and stress echocardiography are described and finally when other imaging techniques may be useful.

Open access

Echocardiography and monitoring patients receiving dopamine agonist therapy for hyperprolactinaemia: a joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology

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.

Open access

A minimum dataset for a Level 1 echocardiogram: a guideline protocol from the British Society of Echocardiography

Rakhee Hindocha, David Garry, Nadia Short, Tom E Ingram, Richard P Steeds, Claire L Colebourn, Keith Pearce, Vishal Sharma, and the Accreditation and Education Committees of the British Society of Echocardiography

The British Society of Echocardiography has previously outlined a minimum dataset for a standard transthoracic echocardiogram, and this remains the basis on which an echocardiographic study should be performed. The importance of ultrasound in excluding critical conditions that may require urgent treatment is well known. Several point-of-care echo protocols have been developed for use by non-echocardiography specialists. However, these protocols are often only used in specific circumstances and are usually limited to 2D echocardiography. Furthermore, although the uptake in training for these protocols has been reasonable, there is little in the way of structured support available from accredited sonographers in the ongoing training and re-accreditation of those undertaking these point-of-care scans. In addition, it is well recognised that the provision of echocardiography on a 24/7 basis is extremely challenging, particularly outside of tertiary cardiac centres. Consequently, following discussions with NHS England, the British Society of Echocardiography has developed the Level 1 echocardiogram in order to support the rapid identification of critical cardiac pathology that may require emergency treatment. It is intended that these scans will be performed by non-specialists in echocardiography and crucially are not designed to replace a full standard transthoracic echocardiogram. Indeed, it is expected that a significant number of patients, in whom a Level 1 echocardiogram is required, will need to have a full echocardiogram performed as soon as is practically possible. This document outlines the minimum dataset for a Level 1 echocardiogram. The accreditation process for Level 1 echo is described separately.

Open access

A practical guideline for performing a comprehensive transthoracic echocardiogram in adults: the British Society of Echocardiography minimum dataset

Shaun Robinson, Bushra Rana, David Oxborough, Rick Steeds, Mark Monaghan, Martin Stout, Keith Pearce, Allan Harkness, Liam Ring, Maria Paton, Waheed Akhtar, Radwa Bedair, Sanjeev Bhattacharyya, Katherine Collins, Cheryl Oxley, Julie Sandoval, Rebecca Schofield MBChB, Anjana Siva, Karen Parker, James Willis, and Daniel X Augustine

Since cardiac ultrasound was introduced into medical practice around the middle twentieth century, transthoracic echocardiography has developed to become a highly sophisticated and widely performed cardiac imaging modality in the diagnosis of heart disease. This evolution from an emerging technique with limited application, into a complex modality capable of detailed cardiac assessment has been driven by technological innovations that have both refined ‘standard’ 2D and Doppler imaging and led to the development of new diagnostic techniques. Accordingly, the adult transthoracic echocardiogram has evolved to become a comprehensive assessment of complex cardiac anatomy, function and haemodynamics. This guideline protocol from the British Society of Echocardiography aims to outline the minimum dataset required to confirm normal cardiac structure and function when performing a comprehensive standard adult echocardiogram and is structured according to the recommended sequence of acquisition. It is recommended that this structured approach to image acquisition and measurement protocol forms the basis of every standard adult transthoracic echocardiogram. However, when pathology is detected and further analysis becomes necessary, views and measurements in addition to the minimum dataset are required and should be taken with reference to the appropriate British Society of Echocardiography imaging protocol. It is anticipated that the recommendations made within this guideline will help standardise the local, regional and national practice of echocardiography, in addition to minimising the inter and intra-observer variation associated with echocardiographic measurement and interpretation.

Open access

The role of TTE in assessment of the patient before and following TAVI for AS

John Fryearson, Nicola C Edwards, Sagar N Doshi, and Richard P Steeds

Transcatheter aortic valve implantation is now accepted as a standard mode of treatment for an increasingly large population of patients with severe aortic stenosis. With the availability of this technique, echocardiographers need to be familiar with the imaging characteristics that can help to identify which patients are best suited to conventional surgery or transcatheter aortic valve implantation, and what parameters need to be measured. This review highlights the major features that should be assessed during transthoracic echocardiography before presentation of the patient to the ‘Heart Team’. In addition, this review summarises the aspects to be considered on echocardiography during follow-up assessment after successful implantation of a transcatheter aortic valve.

Open access

Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO): echocardiography performance protocol

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.

Open access

Feasibility of proximal right coronary artery imaging by 2D and 3D echocardiography in comparison to coronary angiography

Stephan Stoebe, Katharina Lange, Dietrich Pfeiffer, and Andreas Hagendorff

The present study was carried out to test the feasibility of proximal right coronary artery (RCA) imaging and to detect proximal RCA narrowing and occlusion by 2D and 3D transthoracic echocardiography in comparison to coronary angiography (CA). Standardised 2D and 3D echocardiography were performed prior to CA in 97 patients with sinus rhythm. The following parameters were determined: the longest longitudinal detectable RCA segment, the minimum and maximum width of the RCA, the area and number of detectable narrowing >50% of the proximal RCA and the correlation between the echocardiographic and angiographic findings. The visualisation of the proximal RCA and the detection of coronary artery narrowing in the proximal RCA are generally possible. Differences in width and area were not statistically significant between 2D and 3D echocardiography, but showed significant differences between echocardiography and CA. For the detection of proximal RCA narrowing, higher sensitivity and specificity values were obtained by 2D than by 3D echocardiography. However, in patients with sufficient image quality 3D echocardiography permits a more detailed visualisation of the anatomical proportions and an en-face view into the RCA ostium. The visualisation of the proximal RCA is feasible and narrowing can be detected by 2D and 3D echocardiography if image quality is sufficient. CA is the gold standard for the detection of coronary artery stenoses. However, the potential of this new approach is clinically important because crucial findings of the proximal RCA can be presumably detected non-invasively prior to CA.

Open access

Clinical and echocardiographic follow-up of patients following surgical heart valve repair or replacement: a tertiary centre experience

Bashir Alaour, Christina Menexi, and Benoy N Shah

International best practice guidelines recommend lifelong follow-up of patients that have undergone valve repair or replacement surgery and provide recommendations on the utilization of echocardiography during follow-up. However, such follow-up regimes can vary significantly between different centres and sometimes within the same centre. We undertook this study to determine the patterns of clinical follow-up and use of transthoracic echocardiography (TTE) amongst cardiologists in a large UK tertiary centre. In this retrospective study, we identified patients that underwent heart valve repair or replacement surgery in 2008. We used local postal codes to identify patients within our hospital’s follow-up catchment area. We determined the frequency of clinical follow-up and use of transthoracic echocardiography (TTE) during the 9-year follow-up period (2009–2016 inclusive). Of 552 patients that underwent heart valve surgery, 93 (17%) were eligible for local follow-up. Of these, the majority (61/93, 66%) were discharged after their 6-week post-operative check-up with no further follow-up. Of the remaining 32 patients, there was remarkable heterogeneity in follow-up regimes and use of TTE. This variation did not correlate with the prosthesis type. In summary, the frequency of clinical follow-up and use of echocardiography is highly variable in contemporary practice. Many patients are inappropriately discharged back to their family doctor with no plans for hospital follow-up. These data further support the creation of dedicated specialist heart valve clinics to optimize patient care, ensure rational use of TTE and optimize adherence with best practice guidelines.