Risk Assessment of the Cardiac Pregnant Patient.

Women with heart disease are at increased risk for maternal and fetal complications in pregnancy. Therefore, all women with heart disease should undergo evaluation and counseling, ideally before conception, or as early in pregnancy as possible. In this article we will review the role of risk assessment, the history of development of the cardiac risk prediction tools, and the role of current cardiac risk prediction tools.

Incremental diagnostic yield of pediatric cardiac assessment after fetal echocardiography in the offspring of women with congenital heart disease: a prospective study.

OBJECTIVE: We sought to determine the incremental diagnostic utility of pediatric cardiac assessment in the offspring of women with congenital heart disease who have had previous fetal echocardiography. PATIENTS AND METHODS: We prospectively followed pregnant women with congenital heart disease who were receiving care at 2 obstetric and cardiac centers and identified 276 infants who underwent both fetal echocardiography and pediatric cardiac assessment. All of the infants with abnormal fetal echocardiography findings or abnormal pediatric cardiac assessments underwent subsequent confirmatory pediatric echocardiography. RESULTS: In this cohort, congenital heart disease was detected in 22 (8%) of 276 offspring born to women with congenital heart disease. There was concordance between the results of fetal echocardiography and pediatric cardiac assessment in 235 (85%) of 276 offspring (231, both normal; 4, both abnormal) and discordance between the results of fetal echocardiography and pediatric cardiac assessment in 41 (15%) of 276 infants. In the 41 subjects with discordant results, there were normal fetal echocardiography findings but abnormal pediatric cardiac assessments in 35 of 41 (pediatric echocardiography revealed congenital heart disease in 18 of 35 and normal anatomy in 17 of 35) and abnormal fetal echocardiography findings but normal pediatric cardiac assessments in 6 of 41 (pediatric echocardiography findings normal in all 6 of the infants). Fetal echocardiography detected all of the major forms of congenital heart disease. Lesions missed by fetal echocardiography but detected on pediatric cardiac assessment included shunt lesions and minor valvular abnormalities. CONCLUSIONS: Although fetal echocardiography can reliably exclude major forms of congenital heart disease, minor congenital heart disease lesions can be missed on fetal echocardiography; however, these can be diagnosed with careful pediatric cardiac assessment. Postnatal pediatric cardiac assessment has incremental diagnostic utility for the detection of congenital heart disease in the offspring of women with congenital heart disease and previous fetal echocardiography.

The assessment of technical and interpretative proficiency in echocardiography.

OBJECTIVES: We sought to assess the relationship between traditional measures of proficiency in echocardiography and an objective assessment of technical and interpretative skills. BACKGROUND: Determination of competency in echocardiography is currently based on the number of months of training, echocardiograms scanned, and echocardiograms interpreted. It has not been established whether completion of these requirements is a surrogate for competency. METHODS: In all, 22 cardiology fellows underwent an echocardiography objective structured clinical examination (OSCE). RESULTS: There was a correlation between the number of echocardiograms scanned and the interpretation (r = 0.45, P = .038) and scanning (r = 0.42, P = .048) scores. There was a weak correlation between the number of echocardiograms interpreted and interpretation scores (r = 0.33); and number of months of training and the scanning (r = 0.39) and interpretation (r = 0.42) scores. CONCLUSIONS: Technical and interpretative proficiency in echocardiography is not related to traditional measures. An objective assessment of acquisition and interpretation of echocardiographic data should be incorporated into the assessment of proficiency in echocardiography.

Assessment of systemic right ventricular function in patients with transposition of the great arteries using the myocardial performance index: comparison with cardiac magnetic resonance imaging.

BACKGROUND: Assessment of systemic right ventricular (RV) function is a key point in the follow-up of patients with transposition of the great arteries (TGA). Current echocardiographic assessment of RV function is at best an estimate, and cardiac magnetic resonance (CMR) is considered the gold standard. However, this technique is expensive, has limited availability, and requires significant expertise to acquire and interpret the images. The myocardial performance index (MPI) has recently been studied for assessment of pulmonary RV function and shows promise as a simple yet powerful tool for assessing patients with RV dysfunction of various origins. We set out to compare MPI and CMR assessment of systemic RV function in patients with TGA. METHODS AND RESULTS: Data from patients with TGA (11 with congenitally corrected TGA, 18 with surgically corrected TGA) who had CMR within 6 months of their echocardiogram were reviewed. The average systemic RV ejection fraction (RVEF) by CMR was 39.4+/-11.4%, and the systemic RVMPI for this group was 0.56+/-0.21. There was a strong negative correlation between the systemic RVMPI and systemic RVEF by CMR (r=-0.82, P<0.01). The systemic RVEF can be estimated from this formula: RVEF=65%-(45.2xMPI). CONCLUSIONS: MPI can be used in patients with systemic RVs to assess global function and to estimate an EF with good accuracy.

Incremental value of parametric quantitative assessment of myocardial perfusion by triggered Low-Power myocardial contrast echocardiography.

OBJECTIVES: The purpose of this study was to compare the assessment of myocardial perfusion by myocardial parametric quantification (MPQ) with technetium-99m sestamibi single-photon emission computed tomographic (SPECT) imaging in humans. BACKGROUND: Accurate visual interpretation of myocardial contrast echocardiographic (MCE) images is qualitative and requires considerable experience. Current computer-assisted quantitative perfusion protocols are tedious and lack spatial resolution. Myocardial parametric quantification is a novel method that quantifies, color encodes, and displays perfusion data as a set of myocardial parametric images according to the relative degree of perfusion. METHODS: Forty-six consecutive patients underwent prospective stress/rest technetium-99m sestamibi gated-SPECT imaging and MCE using intravenous Optison or Definity. Apical two- and four-chamber cine loops at rest and after dipyridamole (0.56 mg/kg) stress were acquired. For each patient, the following assessments of myocardial perfusion were performed: 1). visual cine-loop assessment (VIS); 2). MPQ assessment; and 3). combined VIS + MPQ assessment. RESULTS: The segmental rates of agreement for myocardial perfusion with SPECT were 83%, 89%, and 92% (kappa = 0.46, 0.58, and 0.68) for VIS, MPQ, and VIS + MPQ, respectively. Similar trends were seen for the classification of the presence or absence of a moderate to severe perfusion defect, with the agreement for VIS, MPQ, and VIS + MPQ being 92%, 97%, and 97%, respectively. CONCLUSIONS: Myocardial parametric quantification demonstrates good agreement with SPECT and incremental agreement with VIS. Analysis strategies that incorporate MPQ demonstrate better agreement with SPECT than visual analysis alone.

Economic impact of contrast stress echocardiography on the diagnosis and initial treatment of patients with suspected coronary artery disease.

OBJECTIVE: To estimate the impact of contrast stress echocardiography on resource use in the treatment of patients with suspected coronary artery disease (CAD). METHODS: Fifty-nine patients with suspected CAD underwent nuclear perfusion imaging and contrast echocardiography examination. Further treatment was planned after each test and a final treatment was recommended after reviewing the results of both examinations. Medical resources and productivity losses were then collected for a 3-month follow-up period. RESULTS: Diagnosis was possible in 96.6% of patients with nuclear perfusion imaging and 93.2% with contrast echocardiography, resulting in a cost per successful diagnosis of $637 (Can) and $476 (Can), respectively. For the majority of patients (74%), both tests provided the same result, but for 12 patients nuclear imaging suggested abnormal perfusion, whereas contrast echocardiography indicated normal function and for 2 patients it was the opposite situation. Per-patient costs for the total patient population decreased from $316 (Can) after nuclear perfusion imaging to $250 (Can) when results from both tests were known. Three-month follow-up societal costs were $441 (Can) per patient, with hospitalization contributing 58% of this total cost. CONCLUSION: Contrast echocardiography has a similar success rate to nuclear perfusion imaging in diagnosing CAD, but has a 28% lower cost and has the potential of additional cost savings through the elimination of further diagnostic tests.