Jun K Teoh and Richard P Steeds
Boyang Liu, Nicola C Edwards, Simon Ray and Richard P Steeds
Mitral regurgitation (MR) is the second most common form of valvular disease requiring surgery. Correct identification of surgical candidates and optimising the timing of surgery are key in management. For primary MR, this relies upon a balance between the peri-operative risks and rates of successful repair in patients undergoing early surgery when asymptomatic with the potential risk of irreversible left ventricular dysfunction if intervention is performed too late. For secondary MR, recognition that this is a highly dynamic condition where MR severity may change is key, although data on outcomes in determining whether concomitant valve intervention is performed with revascularisation has raised questions regarding timing of surgery. There has been substantial interest in the use of stress echocardiography to risk stratify patients in mitral regurgitation. This article reviews the role of stress echocardiography in both primary and secondary mitral regurgitation and discusses how this can help clinicians tackle the challenges of this prevalent condition.
John B Chambers and Richard P Steeds
As heart valve disease increases in prevalence in an ageing population, comorbidities make patients increasingly hard to assess. Specialist competencies are therefore increasingly important to deliver best practice in a specialist valve clinic and to make best advantage of advances in percutaneous and surgical interventions. However, patient care is not improved unless all disciplines have specialist valve competencies, and there is little guidance about the practical details of running a specialist valve clinic. In this issue of Echo Research and Practice, the British Heart Valve Society (BHVS) and the British Society of Echocardiography (BSE) introduce a series of articles to guide all disciplines in how to run a valve clinic.
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.
Rakhee Hindocha, David Garry, Nadia Short, Tom E Ingram, Richard P Steeds, Claire Louise Colebourn, Keith Pearce and Vishal Sharma
The British Society of Echocardiography has previously outlined a minimum dataset for a standard trans-thoracic 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 have 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 is not designed to replace a full standard trans-thoracic 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.
Girish Dwivedi, Ganadevan Mahadevan, Donie Jimenez, Michael Frenneaux and Richard P Steeds
Only limited data are available from which normal ranges of mitral annular (MA) and tricuspid annular (TA) dimensions have been established. Normative data are important to assist the echocardiographer in defining the mechanism of atrioventricular valve regurgitation and to inform surgical planning. This study was conceived to establish normal MA and TA dimensions. Consecutive healthy subjects over the age of 60 were randomly recruited from the community as part of a screening project within South Birmingham. MA and TA dimensions in end-systole and end-diastole were evaluated in the parasternal and apical acoustic windows views using transthoracic echocardiography. Gender (males (M) and females (F))-specific dimensions were then assessed. A total of 554 subjects were screened and 74 with pathology considered to have an effect on annular dimensions were excluded from analysis. The mean age of the remaining 480 subjects was 70±7 years and the majority were female (56%). Dimensions were larger in men than in women and greater at end-diastole than end-systole (both P<0.05). Mean MA diameters at end-systole in the parasternal long axis view (cm) were 3.44 cm (M) and 3.11 cm (F) and at end-diastole 3.15 cm (M) and 2.83 cm (F) respectively. Mean TA diameters (cm) at end-systole in the apical 4 chamber view were 2.84 (M) and 2.80 (F) and at end-diastole 3.15 (M) and 3.01 (F) respectively. The reference ranges derived from this study differ from current published standards and should help to improve distinction of normal from pathological findings, in identifying aetiology and defining the mechanism of regurgitation.
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.
Richard Wheeler, Richard Steeds, Bushra Rana, Gill Wharton, Nicola Smith, Jane Allen, John Chambers, Richard Jones, Guy Lloyd, Kevin O'Gallagher and Vishal Sharma
A systematic approach to transoesophageal echocardiography (TOE) is essential to ensure that no pathology is missed during a study. In addition, a standardised approach facilitates the education and training of operators and is helpful when reviewing studies performed in other departments or by different operators. This document produced by the British Society of Echocardiography aims to provide a framework for a standard TOE study. In addition to a minimum dataset, the layout proposes a recommended sequence in which to perform a comprehensive study. It is recommended that this standardised approach is followed when performing TOE in all clinical settings, including intraoperative TOE to ensure important pathology is not missed. Consequently, this document has been prepared with the direct involvement of the Association of Cardiothoracic Anaesthetists (ACTA).
Nicola Smith, Richard Steeds, Navroz Masani, Julie Sandoval, Gill Wharton, Jane Allen, John Chambers, Richard Jones, Guy Lloyd, Bushra Rana, Kevin O'Gallagher, Richard Wheeler and Vishal Sharma
Hypertrophic cardiomyopathy (HCM) is a relatively common inherited cardiac condition with a prevalence of approximately one in 500. It results in otherwise unexplained hypertrophy of the myocardium and predisposes the patient to a variety of disease-related complications including sudden cardiac death. Echocardiography is of vital importance in the diagnosis, assessment and follow-up of patients with known or suspected HCM. The British Society of Echocardiography (BSE) has previously published a minimum dataset for transthoracic echocardiography, providing the core parameters necessary when performing a standard echocardiographic study. However, for patients with known or suspected HCM, additional views and measurements are necessary. These additional views allow more subtle abnormalities to be detected or may provide important information in order to identify patients with an adverse prognosis. The aim of this Guideline is to outline the additional images and measurements that should be obtained when performing a study on a patient with known or suspected HCM.
Thomas Mathew, Lynne Williams, Govardhan Navaratnam, Bushra Rana, Richard Wheeler, Katherine Collins, Allan Harkness, Richard Jones, Dan Knight, Kevin O'Gallagher, David Oxborough, Liam Ring, Julie Sandoval, Martin Stout, Vishal Sharma, Richard P Steeds and on behalf of the British Society of Echocardiography Education Committee
Heart failure (HF) is a debilitating and life-threatening condition, with 5-year survival rate lower than breast or prostate cancer. It is the leading cause of hospital admission in over 65s, and these admissions are projected to rise by more than 50% over the next 25 years. Transthoracic echocardiography (TTE) is the first-line step in diagnosis in acute and chronic HF and provides immediate information on chamber volumes, ventricular systolic and diastolic function, wall thickness, valve function and the presence of pericardial effusion, while contributing to information on aetiology. Dilated cardiomyopathy (DCM) is the third most common cause of HF and is the most common cardiomyopathy. It is defined by the presence of left ventricular dilatation and left ventricular systolic dysfunction in the absence of abnormal loading conditions (hypertension and valve disease) or coronary artery disease sufficient to cause global systolic impairment. This document provides a practical approach to diagnosis and assessment of dilated cardiomyopathy that is aimed at the practising sonographer.