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Madalina Garbi and Mark J Monaghan

Quantitative analysis is an important part of the morphological assessment of the diseased mitral valve. It can be used to describe valve anatomy, pathology, function and the mechanisms of disease. Echocardiography is the main source of indirect quantitative data that is comparable with direct anatomic or surgical measurements. Furthermore, it can relate morphology with function. This review provides an account of current mitral valve quantification techniques and clinical applications.

Open access

Sitara G Khan, Dimitris Klettas, Stam Kapetanakis, and Mark J Monaghan


Cardiac resynchronisation therapy (CRT) can profoundly improve outcome in selected patients with heart failure; however, response is difficult to predict and can be absent in up to one in three patients. There has been a substantial amount of interest in the echocardiographic assessment of left ventricular dyssynchrony, with the ultimate aim of reliably identifying patients who will respond to CRT. The measurement of myocardial deformation (strain) has conventionally been assessed using tissue Doppler imaging (TDI), which is limited by its angle dependence and ability to measure in a single plane. Two-dimensional speckle-tracking echocardiography is a technique that provides measurements of strain in three planes, by tracking patterns of ultrasound interference (‘speckles’) in the myocardial wall throughout the cardiac cycle. Since its initial use over 15 years ago, it has emerged as a tool that provides more robust, reproducible and sensitive markers of dyssynchrony than TDI. This article reviews the use of two-dimensional and three-dimensional speckle-tracking echocardiography in the assessment of dyssynchrony, including the identification of echocardiographic parameters that may hold predictive potential for the response to CRT. It also reviews the application of these techniques in guiding optimal LV lead placement pre-implant, with promising results in clinical improvement post-CRT.

Open access

Alexandros Papachristidis, Damian Roper, Daniela Cassar Demarco, Ioannis Tsironis, Michael Papitsas, Jonathan Byrne, Khaled Alfakih, and Mark J Monaghan


In this study, we aim to reassess the prognostic value of stress echocardiography (SE) in a contemporary population and to evaluate the clinical significance of limited apical ischaemia, which has not been previously studied.


We included 880 patients who underwent SE. Follow-up data with regards to MACCE (cardiac death, myocardial infarction, any repeat revascularisation and cerebrovascular accident) were collected over 12 months after the SE. Mortality data were recorded over 27.02 ± 4.6 months (5.5–34.2 months). We sought to investigate the predictors of MACCE and all-cause mortality.


In a multivariable analysis, only the positive result of SE was predictive of MACCE (HR, 3.71; P = 0.012). The positive SE group was divided into 2 subgroups: (a) inducible ischaemia limited to the apical segments (‘apical ischaemia’) and (b) ischaemia in any other segments with or without apical involvement (‘other positive’). The subgroup of patients with apical ischaemia had a significantly worse outcome compared to the patients with a negative SE (HR, 3.68; P = 0.041) but a similar outcome to the ‘other positive’ subgroup. However, when investigated with invasive coronary angiography, the prevalence of coronary artery disease (CAD) and their rate of revascularisation was considerably lower. Only age (HR, 1.07; P < 0.001) was correlated with all-cause mortality.


SE remains a strong predictor of patients’ outcome in a contemporary population. A positive SE result was the only predictor of 12-month MACCE. The subgroup of patients with limited apical ischaemia have similar outcome to patients with ischaemia in other segments despite a lower prevalence of CAD and a lower revascularisation rate.

Open access

Richard P Steeds, Richard Wheeler, Sanjeev Bhattacharyya, Joseph Reiken, Petros Nihoyannopoulos, Roxy Senior, Mark J Monaghan, and Vishal Sharma

Stress echocardiography is an established technique for assessing coronary artery disease. It has primarily been used for the diagnosis and assessment of patients presenting with chest pain in whom there is an intermediate probability of coronary artery disease. In addition, it is used for risk stratification and to guide revascularisation in patients with known ischaemic heart disease. Although cardiac computed tomography has recently been recommended in the United Kingdom as the first-line investigation in patients presenting for the first time with atypical or typical angina, stress echocardiography continues to have an important role in the assessment of patients with lesions of uncertain functional significance and patients with known ischaemic heart disease who represent with chest pain. In this guideline from the British Society of Echocardiography, the indications and recommended protocols are outlined for the assessment of ischaemic heart disease by stress echocardiography.

Open access

Vishal Sharma, Martin Stout, Keith Pearce, Allan L Klein, Maryam Alsharqi, Petros Nihoyannopoulos, Jamal Nasir Khan, Timothy Griffiths, Kully Sandhu, Sinead Cabezon, Chun Shing Kwok, Shanat Baig, Tamara Naneishvili, Vetton Chee Kay Lee, Arron Pasricha, Emily Robins, Prathap Kanagala, Tamseel Fatima, Andreea Mihai, Robert Butler, Simon Duckett, Grant Heatlie, Haotian Gu, Phil Chowienczyk, Linda Arnold, Sean Coffey, Margaret Loudon, Jo Wilson, Andrew Kennedy, Saul G Myerson, Bernard Prendergast, Alice M Jackson, Vera Lennie, Peter Lee Luke, Christopher James Eggett, Loakim Spyridopoulos, Timothy Simon Irvine, Nashwah Ismail, Anita Macnab, Caroline Bleakley, Mehdi Eskandari, Omar Aldalati, Almira Whittaker, Marilou Huang, Mark J Monaghan, Thomas J Turner, Conor Steele, Anna Barton, Alan C Cameron, Sonecki Piotr, Phang Gyee Vuei, Christos Voukalis, Hwee Phen Teh, Stavros Apostolakis, Chih Wong, Matthew M Y Lee, Nicolas E R Goodfield, Emma Lane, David Slessor, Richard Crawley, Theodoros Ntoskas, Farhanda Ahmad, Paul Woodmansey, Andrew J Fletcher, Shaun Robinson, Bushra S Rana, Liam Batchelor, Brogan McAdam, Caroline J Coats, Louise C Mayall, Niall G Campbell, and Hannah Garnett