3-D transesophageal echocardiography aids in assessment of embolic stroke due to aortic atherosclerotic plaque: A case series.

Atherosclerosis is the most common cause of heart disease and stroke. Plaque thickness ≥4 mm in the ascending aorta or aortic arch is strongly correlated with cerebral embolic events and ischemic stroke. However, despite imaging workup, the cause of embolic stroke remains unidentified in many patients. Transesophageal echocardiography (TEE) is the preferred echocardiographic method for the evaluation of cardiac source of emboli. 2D TEE imaging evaluates aortic root and aortic arch in a single plane or two planes with biplane imaging. However, 2D TEE often fails to detect mobile or complex components in the ascending aorta and aortic arch plaques. The routine availability of 3D TEE in current ultrasound systems may significantly improve the assessment of aortic plaques as a potential embolic source. In this case series, we present four consecutive patients with stroke who underwent TEE by a single cardiologist for possible cardioembolic source. Some of these patients may have been labelled as "cryptogenic stroke" or "embolic stroke of undetermined source" (ESUS) due to the presence of insignificant or nonmobile ascending aortic or aortic arch plaques on 2D TEE imaging. In our four consecutive patients with ESUS who underwent TEE by a single operator, 3D TEE showed complex aortic arch plaques with ulceration with mobile components and established these plaques as the likely source of embolic stroke.

Aortic Valve Calcium Score by Computed Tomography as an Adjunct to Echocardiographic Assessment-A Review of Clinical Utility and Applications.

Aortic valve stenosis (AS) is increasing in prevalence due to the aging population, and severe AS is associated with significant morbidity and mortality. Echocardiography remains the mainstay for the initial detection and diagnosis of AS, as well as for grading of severity. However, there are important subgroups of patients, for example, patients with low-flow low-gradient or paradoxical low-gradient AS, where quantification of severity of AS is challenging by echocardiography and underestimation of severity may delay appropriate management and impart a worse prognosis. Aortic valve calcium score by computed tomography has emerged as a useful clinical diagnostic test that is complimentary to echocardiography, particularly in cases where there may be conflicting data or clinical uncertainty about the degree of AS. In these situations, aortic valve calcium scoring may help re-stratify grading of severity and, therefore, further direct clinical management. This review presents the evolution of aortic valve calcium score by computed tomography, its diagnostic and prognostic value, as well as its utility in clinical care.

Is there a silver lining for US health care from COVID-19 pandemic?

The COVID-19 pandemic has had an impact on economy and health care system of every nation. United States has been the hardest hit country both with incidence and absolute mortality from COVID-19. In some of its states the health care system have been stretched to their limits. This has led to a rapid change in the health care practice due to newly approved emergency legislative bills, new state government laws, measures taken by institutions and practices as well as the changing consumer behavior. Some of these adaptations - in particular, the transition of patient care to virtual visits are revolutionary. Increased vigilance by health care organization and workers to minimize the spread of infection to others as well for personal protection may result in lasting behavioral change that will prevent hospital acquired or transmitted infections and may lead to reduced morbidity and mortality from the regular "flu". The recycling of personal protective equipment and the emerging research showing it a safe practice will reduce health care expenditure. It is quite possible that this pandemic may be the silver lining that will save the US health care from its unsustainable consumption of US gross domestic product.

Recommendations for the Assessment of Carotid Arterial Plaque by Ultrasound for the Characterization of Atherosclerosis and Evaluation of Cardiovascular Risk: From the American Society of Echocardiography.

Atherosclerotic plaque detection by carotid ultrasound provides cardiovascular disease risk stratification. The advantages and disadvantages of two-dimensional (2D) and three-dimensional (3D) ultrasound methods for carotid arterial plaque quantification are reviewed. Advanced and emerging methods of carotid arterial plaque activity and composition analysis by ultrasound are considered. Recommendations for the standardization of focused 2D and 3D carotid arterial plaque ultrasound image acquisition and measurement for the purpose of cardiovascular disease stratification are formulated. Potential clinical application towards cardiovascular risk stratification of recommended focused carotid arterial plaque quantification approaches are summarized.

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons.

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document1 addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines. A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Carotid intima-media thickness and plaque in cardiovascular risk assessment.

Carotid intima-media thickness (CIMT) has been shown to predict cardiovascular (CV) risk in multiple large studies. Careful evaluation of CIMT studies reveals discrepancies in the comprehensiveness with which CIMT is assessed-the number of carotid segments evaluated (common carotid artery [CCA], internal carotid artery [ICA], or the carotid bulb), the type of measurements made (mean or maximum of single measurements, mean of the mean, or mean of the maximum for multiple measurements), the number of imaging angles used, whether plaques were included in the intima-media thickness (IMT) measurement, the report of adjusted or unadjusted models, risk association versus risk prediction, and the arbitrary cutoff points for CIMT and for plaque to predict risk. Measuring the far wall of the CCA was shown to be the least variable method for assessing IMT. However, meta-analyses suggest that CCA-IMT alone only minimally improves predictive power beyond traditional risk factors, whereas inclusion of the carotid bulb and ICA-IMT improves prediction of both cardiac risk and stroke risk. Carotid plaque appears to be a more powerful predictor of CV risk compared with CIMT alone. Quantitative measures of plaques such as plaque number, plaque thickness, plaque area, and 3-dimensional assessment of plaque volume appear to be progressively more sensitive in predicting CV risk than mere assessment of plaque presence. Limited data show that plaque characteristics including plaque vascularity may improve CV disease risk stratification further. IMT measurement at the CCA, carotid bulb, and ICA that allows inclusion of plaque in the IMT measurement or CCA-IMT measurement along with plaque assessment in all carotid segments is emerging as the focus of carotid artery ultrasound imaging for CV risk prediction.

Posterior thoracic echocardiography for assessment of native and prosthetic aortic valves in the presence of pleural effusion.

Many patients with aortic stenosis have difficult imaging windows due to advanced age, kyphosis, prior chest surgeries, radiation-induced skin changes, or hyperinflated lungs from pulmonary disease. Here we describe 4 cases to illustrate that in a subset of patients with pleural effusion, a posterior imaging approach can be used to obtain diagnostic images for native and prosthetic aortic valves. In these cases, nondiagnostic transthoracic echocardiographic images were obtained from conventional imaging windows, leading to inaccurate or incomplete assessment of the aortic valve. In all cases, images obtained from a posterior thoracic approach provided important additional diagnostic information.

Carotid intima-media thickness and plaque assessment by trained medical residents: validation and preliminary testing of a training protocol.

BACKGROUND: Training of nonsonographer physicians or staff members is needed to implement carotid intima-media thickness (CIMT) and plaque screening by ultrasound for the assessment of subclinical atherosclerosis. The purpose of this study was to determine the effect of formal training on CIMT assessment and plaque detection by medical residents. METHODS: A medical resident (R1) was trained using an abbreviated American Society of Echocardiography CIMT protocol. CIMT and plaque assessment by R1 were compared against an expert scanner on 60 subjects using a portable US system. A second medical resident (R2) was then trained on the CIMT protocol focusing on plaque visualization after the results of the first phase of the study were analyzed, and the results were compared against an expert on an additional 10 subjects. RESULTS: In the first phase of the study, a total of 106 images (94% interpretable) were available for CIMT and plaque assessment by both R1 and the expert. CIMT measurements were bioequivalent within the limits of ultrasound resolution, with 88% agreement. Variability on plaque presence was high, with only 53% agreement. R2 and the expert each scanned 10 new subjects twice, from whom 40 images were available for interpretation. R2 demonstrated CIMT agreement (93%) comparable with that observed in phase 1 but with greatly improved plaque agreement (100%). Intraobserver variability during phase 2 for both R2 and the expert was extremely low. CONCLUSIONS: Medical residents can undergo rapid training for CIMT measurement and plaque visualization to detect subclinical atherosclerosis compared with an expert.

Echocardiography-guided biventricular pacemaker optimization: role of echo Doppler in hemodynamic assessment and improvement.

In spite of improvements in heart failure management and increasing utilization of cardiac resynchronization therapy (CRT), approximately 30-40% of CRT patients remain nonresponders and 50% or more are echocardiographic nonresponders (defined as less than 15% reduction in left ventricular end systolic volume post-CRT). Optimization guided by echocardiography has been studied as one of the methods to improve the nonresponder rate to CRT. Echo-guided biventricular (Biv) pacemaker optimization has been associated with improvement in acute cardiac hemodynamics and improvement in functional class. In this review, the authors discuss various methods to optimize Biv pacemaker by echocardiography, recent advances in pacemaker optimization and the limitations of echocardiography. The authors also demonstrate complex hemodynamic derangements in heart failure via multiple case examples highlighting the role of comprehensive echo Doppler in elucidating cardiac hemodynamics encountered in CRT nonresponders, as well as tailoring of Biv pacemaker optimization to the underlying physiologic derangement.

Reduction in mitral regurgitation in patients undergoing cardiac resynchronization treatment: assessment of predictors by two-dimensional radial strain echocardiography.

BACKGROUND: We utilized the novel approach of 2D radial strain (2-DRS) to evaluate whether left ventricular (LV) mechanical dyssynchrony in mid-LV segments corresponding to papillary muscles insertion sites can predict early mitral regurgitation (MR) reduction post-cardiac resynchronization therapy (CRT). METHODS: We evaluated 32 patients undergoing CRT (mean age 64 +/- 17 years, 54% males) with MR grade > or =3 determined by the MR jet area/left atrial area ratio (JA/LAA). RESULTS: Fifteen (47%) patients responded to CRT (JA/LAA) < 25%). Sixty-seven percent of responders had mild or no residual MR and 33% had mild-to-moderate MR, while 70% of nonresponders had grade 3 or 4 MR (P = 0.0001) post CRT. The percent reduction in LV end-systolic volume was significantly higher in responders (P = 0.03), as was improvement in LVEF (P = 0.007). Significant delay of time-to-peak 2-DRS in the midposterior and inferior segments prior to CRT was found in responders compared with nonresponders (580 +/- 58 vs. 486 +/- 94, P = 0.002 and 596 +/- 79 vs. 478 +/- 127 ms, P = 0.005, respectively). Responders also had higher peak positive systolic 2-DRS in the posterior and inferior segments compared to nonresponders (22 +/- 13 vs. 12 +/- 7%, P = 0.01 and 17 +/- 9 vs. 9 +/- 7%, P = 0.02, respectively). Logistic regression analysis showed that the differences in pre-CRT inferoanterior time-to-peak 2-DRS of >110 ms and MRJA/LAA <40% as well as 2-DRS >18% in the posterior wall were significant predictors of post-CRT improvement in MR. CONCLUSION: The presence of a significant time-to-peak delay on 2-DRS between inferior and anterior LV segments, preserved strain of posterior wall, and MRJA/LAA <40% were found to be associated with significant MR reduction in patients post-CRT.

Ultrasound carotid artery intima-media thickness assessment for progression of atherosclerosis in lipid intervention studies.

Atherosclerotic cardiovascular disease is the number one cause of death in Western countries and is a rapidly growing problem worldwide. The majority of patients who present with acute coronary syndrome often have a low cardiovascular risk score, which is insufficient to warrant treatment prior to an acute coronary event. Alternatively, some high risk individuals never develop cardiovascular events. Identification of individuals who are truly at risk before an acute coronary event is critical. The long subclinical incubation period of atherosclerosis and the early involvement of the vessel wall in the disease provides an opportunity to evaluate the presence of atherosclerosis by imaging the arterial wall and to initiate treatment measures prior to an acute coronary event. The assessment of the thickness of the intima-media layer of the vessel wall, as well as detection of early plaques by ultrasound, is non-invasive and is the most sensitive, reliable, and safe method to detect those at risk. It is also the most validated method to detect progression of atherosclerosis. Evaluation of atherosclerosis progression by this technique has been used in large clinical trial settings, however, improvement in imaging and measurement technology may make this suitable for use in individual patients for therapeutic validity both in primary and secondary care settings.

Assessment of aortic stenosis by three-dimensional echocardiography: an accurate and novel approach.

BACKGROUND: Accurate assessment of aortic valve area (AVA) is important for clinical decision-making in patients with aortic valve stenosis (AS). The role of three-dimensional echocardiography (3D) in the quantitative assessment of AS has not been evaluated so far. OBJECTIVES: To evaluate the reproducibility and accuracy of real-time three-dimensional echocardiography (RT3D) and 3D-guided two-dimensional planimetry (3D/2D) for assessment of AS, and compare these results with those of standard echocardiography and cardiac catheterisation (Cath). METHODS: AVA was estimated by transthoracic echo-Doppler (TTE) and by direct planimetry using transoesophageal echocardiography (TEE) as well as RT3D and 3D/2D. 15 patients underwent assessment of AS by Cath. RESULTS: 33 patients with AS were studied (20 men, mean (SD) age 70 (14) years). Bland-Altman analysis showed good agreement and small absolute differences in AVA between all planimetric methods (RT3D vs 3D/2D: -0.01 (0.15) cm(2); 3D/2D vs TEE: 0.05 (0.22) cm(2); RT3D vs TEE: 0.06 (0.26) cm(2)). The agreement between AVA assessment by 2D-TTE and planimetry was -0.01 (0.20) cm(2) for 3D/2D; 0.00 (0.15) cm(2) for RT3D; and -0.05 (0.30) cm(2) for TEE. Correlation coefficient r for AVA assessment between each of 3D/2D, RT3D, TEE planimetry and Cath was 0.81, 0.86 and 0.71, respectively. The intraobserver variability was similar for all methods, but interobserver variability was better for 3D techniques than for TEE (p<0.05). CONCLUSIONS: The 3D echo methods for planimetry of the AVA showed good agreement with the standard TEE technique and flow-derived methods. Compared with AV planimetry by TEE, both 3D methods were at least as good as TEE and had better reproducibility. 3D aortic valve planimetry is a novel non-invasive technique, which provides an accurate and reliable quantitative assessment of AS.

Guidelines for noninvasive vascular laboratory testing: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology.

Accompanying the rapid growth of interest in percutaneous vascular interventions, there has been increasing interest among cardiologists in performing noninvasive vascular testing using ultrasound. In an attempt to provide recommendations on the best practices in vascular laboratory testing, this report has been prepared by a writing group from the American Society of Echocardiography (ASE) and the Society for Vascular Medicine and Biology. The document summarizes principles integral to vascular duplex ultrasound--including color Doppler, spectral Doppler waveform analysis, power Doppler, and the use of contrast. Appropriate indications and interpretation of carotid artery, renal artery, abdominal aorta, and peripheral artery ultrasound imaging are described. A dedicated section summarizes noninvasive techniques for physiologic vascular testing of the lower extremity arteries--including measurement of segmental pressures and pulse volume plethysmography. The use of exercise testing in the evaluation of peripheral artery disease, ultrasound evaluation of the lower extremities after percutaneous revascularization, and the diagnosis and management of iatrogenic pseudoaneurysm (PSA) is also discussed. A section on the important topic of vascular laboratory accreditation is included. Finally, additional details regarding proper technique for performance of the various vascular tests and procedures are included in the Appendix.

Comparison of transthoracic and intraoperative transesophageal color flow Doppler assessment of mitral and aortic regurgitation.

BACKGROUND: We examined the agreement between transthoracic echocardiography (TTE) and intraoperative prepump transesophageal echocardiography (TEE) in the assessment of left-sided regurgitant lesions and echocardiographic variables associated with grading discrepancies. METHODS: The TTE and prepump TEE studies of 54 patients undergoing aortic-valve replacement for aortic stenosis were reviewed. Agreement and correlation in assessment of aortic (AR) and mitral regurgitation (MR) severity were evaluated. RESULTS: There was no significant difference between mean TTE and prepump TEE grading of MR (0.23 +/- 0.19 vs. 0.21 +/- 0.15 jet area/area of the left atrium, p = 0.49), but the correlation between the two methods was weak (r = 0.40, p = 0.003), with an exact agreement of 54%. Prepump TEE tended to grade AR as more severe (mean grade 1.43 +/- 0.94 vs. 1.24 +/- 0.75, p = 0.058). The correlation between the two methods in AR assessment was fair (r = 0.70, p = 0.0001) with an agreement of 59%. For MR and AR grading, no significant correlations between valvular regurgitation severity and blood pressure differences between preoperative TTE and prepump TEE were found. In 17% of cases, discrepancies in identifying severe mitral or aortic valve regurgitation could have affected patient management. CONCLUSIONS: There is modest agreement in MR and AR assessment between TTE and prepump TEE. Cardiologists, cardiac surgeons, and anesthesiologists must be aware of differences between these methods when using prepump TEE to guide intraoperative decisions.