United Kingdom standards for non-invasive cardiac imaging: recommendations from the Imaging Council of the British Cardiovascular Society.

Heart and circulatory diseases affect more than seven million people in the UK. Non-invasive cardiac imaging is a critical element of contemporary cardiology practice. Progressive improvements in technology over the last 20 years have increased diagnostic accuracy in all modalities and led to the incorporation of non-invasive imaging into many standard cardiac clinical care pathways. Cardiac imaging tests are requested by a variety of healthcare practitioners and performed in a range of settings from the most advanced hospitals to local health centres. Imaging is used to detect the presence and consequences of cardiovascular disease, as well as to monitor the response to therapies. The previous UK national imaging strategy statement which brought together all of the non-invasive imaging modalities was published in 2010. The purpose of this document is to collate contemporary standards developed by the modality-specific professional organisations which make up the British Cardiovascular Society Imaging Council, bringing together common and essential recommendations. The development process has been inclusive and iterative. Imaging societies (representing both cardiology and radiology) reviewed and agreed on the initial structure. The final document therefore represents a position, which has been generated inclusively, presents rigorous standards, is applicable to clinical practice and deliverable. This document will be of value to a variety of healthcare professionals including imaging departments, the National Health Service or other organisations, regulatory bodies, commissioners and other purchasers of services, and service users, i.e., patients, and their relatives.

EDUCATIONAL SERIES IN CONGENITAL HEART DISEASE: The sequential segmental approach to assessment.

Sequential segmental analysis allows clear description of the cardiac structure in a logical fashion without assumptions and confusing nomenclature. Each segment is analysed, and then the connections described followed by any associated anomalies. For the echocardiographer there are several key features of the cardiac structures to help differentiate and accurately describe them.

A patient-centred model to quality assure outputs from an echocardiography department: consensus guidance from the British Society of Echocardiography.

Background Quality assurance (QA) of echocardiographic studies is vital to ensure that clinicians can act on findings of high quality to deliver excellent patient care. To date, there is a paucity of published guidance on how to perform this QA. The British Society of Echocardiography (BSE) has previously produced an Echocardiography Quality Framework (EQF) to assist departments with their QA processes. This article expands on the EQF with a structured yet versatile approach on how to analyse echocardiographic departments to ensure high-quality standards are met. In addition, a process is detailed for departments that are seeking to demonstrate to external bodies adherence to a robust QA process. Methods The EQF consists of four domains. These include assessment of Echo Quality (including study acquisition and report generation); Reproducibility & Consistency (including analysis of individual variability when compared to the group and focused clinical audit), Education & Training (for all providers and service users) and Customer & Staff Satisfaction (of both service users and patients/their carers). Examples of what could be done in each of these areas are presented. Furthermore, evidence of participation in each domain is categorised against a red, amber or green rating: with an amber or green rating signifying that a quantifiable level of engagement in that aspect of QA has been achieved. Conclusion The proposed EQF is a powerful tool that focuses the limited time available for departmental QA on areas of practice where a change in patient experience or outcome is most likely to occur.

The Echocardiography Quality Framework: a comprehensive, patient-centered approach to quality assurance and continuous service improvement.

The Echocardiography Quality Framework is a cohesive, patient-centered program, combining quality assurance and continuous service improvement, which can be adapted to suit the needs of any echocardiography department. The framework encompasses measures of the quality of care, reproducibility and consistency, education and training, and customer feedback. The EQF is scalable and adaptable to benefit any echocardiography service. A catalogue or library of supporting documents is being developed, drawing on expertise around the UK, to made available to any participating department. A mechanism and online infrastructure for national registration or assessment is being developed, to be used as a standalone adjunct or linked to BSE Departmental Accreditation. The principles that underpin the EQF may be applicable to other imaging disciplines and, ultimately, other medical or surgical specialties.

Myocardial ischaemia as a result of external coronary compression from infective aortic root aneurysm: atypical presentation of prosthetic valve endocarditis.

SummaryThis case describes an unusual presentation of prosthetic valve endocarditis (PVE): an acute coronary syndrome. A 67-year-old male presented with cardiac sounding chest pain on a background of a short history of night sweats, weight loss and general malaise. Four months previously, he had undergone bio-prosthetic aortic valve replacement for severe aortic stenosis and single vessel bypass grafting of the obtuse marginal. Whilst having chest pain, his ECG showed infero-lateral ST depression. Early coronary angiography revealed a new right coronary artery (RCA) lesion that was not present prior to his cardiac surgery. Using multi-modality cardiac imaging, the diagnosis of PVE was made. An aortic root abscess was demonstrated that was causing external compression of the RCA. LEARNING POINTS: PVE accounts for up to 20% of all cases of infective endocarditis.High clinical suspicion and early blood cultures before empirical antibiotics are key as the presentation of PVE can often be atypical.PVE rarely presents as an acute coronary syndrome. Potential mechanisms by which PVE may result in an ACS include coronary embolization, obstruction of coronary ostia by a large mobile vegetation and external coronary artery compression from an infective aneurysms/abscess.Repeat cardiac surgery is often required for high-risk PVE such as those caused by staphylococcal infection or severe prosthetic dysfunction.

A systematic approach to echocardiography in hypertrophic cardiomyopathy: a guideline protocol from the British Society of Echocardiography.

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.

A minimum dataset for a standard adult transthoracic echocardiogram: a guideline protocol from the British Society of Echocardiography.

There have been significant advances in the field of echocardiography with the introduction of a number of new techniques into standard clinical practice. Consequently, a 'standard' echocardiographic examination has evolved to become a more detailed and time-consuming examination that requires a high level of expertise. This Guideline produced by the British Society of Echocardiography (BSE) Education Committee aims to provide a minimum dataset that should be obtained in a comprehensive standard echocardiogram. In addition, the layout proposes a recommended sequence in which to acquire the images. If abnormal pathology is detected, additional views and measurements should be obtained with reference to other BSE protocols when appropriate. Adherence to these recommendations will promote an increased quality of echocardiography and facilitate accurate comparison of studies performed either by different operators or at different departments.

International evidence-based recommendations for focused cardiac ultrasound.

BACKGROUND: Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS: The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS: During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS: This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Development of a National Echocardiography Quality Improvement Programme: insights into feasibility, uptake, and clinical utility.

AIMS: There are minimal data on methods to measure and improve quality in image interpretation when reporting cardiovascular imaging studies. We sought to identify the feasibility and clinical utility of a nationally implemented quality assurance (QA) process. METHODS AND RESULTS: A web-based platform was developed to administer a national QA module to 27 echocardiography departments within the UK. Three QA modules were delivered from 2011. The proportion of units using the QA module increased from 14 (52.2%) in the first module to 22 (81.5%) in the third module. There was no significant change in the proportion of correct answers between the first module (88.9%) and the third module (82.8%), P = 0.3. The number of echocardiographers with at least one incorrect answer increased from 16 (21.6%) in the first module to 54 (34%) in the third module, P = 0.03. Overall, in valvular heart disease cases there were 36 (10.6%) incorrect responses where qualitative assessment of the severity of valve dysfunction was tested compared with 4 (3.6%) incorrect responses where quantitative assessment of valve dysfunction was tested, P = 0.04. In chamber quantification cases, there were 36 (6.8%) incorrect responses where qualitative assessment of chamber function was tested compared with 3 (2.1%) incorrect responses where quantitative assessment of chamber function was tested, P = 0.04. CONCLUSION: The incorporation of national QA programme is feasible with rapid uptake. The platform allows comparison of an individual's interpretation skills against a reference standard which can be used as a method to identify inter-observer variability and as a training tool.

Aortic annulus diameter and valve design each determine the valve size implanted.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare the sizing characteristics and hemodynamics of the Medtronic Mosaic Ultra porcine and Carpentier-Edwards PERIMOUNT Magna bovine pericardial bioprosthetic stented aortic valves in relation to the patient's true aortic annulus size. METHODS: In this prospective multicenter randomized study, data acquired perioperatively and at six months postoperatively were collected. Following aortic valve excision and debridement, the annulus was measured by blinded sizers prior to the randomization of 141 patients (Ultra, n=72; Magna, n=69). RESULTS: The median patient age was 75 years, and 89% of the patients had aortic stenosis. A good left ventricular function was present in 75% of patients, and the EuroSCORE-predicted mortality was 9%. Concomitant procedures (coronary artery bypass grafting, mitral/tricuspid repair, septal myectomy, modified Maze) were performed in 61% of patients. The in-hospital mortality was 3%, and at six months postoperatively 96% of the patients were NYHA class I or II, with no intergroup differences. The mean 'true aortic annulus' size was 23.0 +/- 1.4 mm for the Ultra valve, and 22.6 +/- 1.8 mm for the Magna valve (p = NS). The implanted labeled valve size was > or = 23 mm for 83% of Ultra valves, and for 52% of Magna valves (p < 0.01), and smaller than the measured true aortic diameter (44% Magna versus 33% Ultra). The mean echo gradients were lower with Magna valves (11 +/- 6 mmHg) than with Ultra (17 +/- 6 mmHg; p < 0.01), while the effective orifice area (EOA) was higher with Magna than with Ultra (1.6 +/- 0.4 versus 1.4 +/- 0.4 ; p < 0.01). Both groups showed a similar left ventricular mass regression (Ultra -48 +/- 83 g; Magna -42 +/- 70 g). Trivial to moderate regurgitation was noted in 24% of Ultra valves compared to 48% of Magna valves (p < 0.01). CONCLUSION: Selection of the Ultra bioprosthetic valve allowed the implantation of larger valve sizes. However, when compared to the 'true aortic annulus', the Magna was associated with lower transprosthetic gradients and larger EOAs. The longer term significance of these observations remains inconclusive in terms of bioprosthesis selection, however.

Echocardiographic assessment of pulmonary hypertension: standard operating procedure.

Patients with suspected pulmonary hypertension (PH) should be evaluated using a multimodality approach to ensure that they receive a correct diagnosis. The series of investigations required includes clinical evaluation, noninvasive imaging techniques and right heart catheterisation (considered to be the "gold standard" for the diagnosis of PH). Current guidelines recommend that a detailed echocardiographic assessment is performed in all patients with suspected PH. In this review we summarise a protocol adopted by the National Pulmonary Hypertension Centres of UK and Ireland and approved by the British Society of Echocardiography for the evaluation of these patients. The views and measurements described are recommended for diagnosis, assisting in prognosis and providing a noninvasive means of following disease progression or response to therapy.

The role of echocardiography in the management of atrial fibrillation.

Atrial fibrillation is the most common arrhythmia in clinical practice and is associated with significant mortality and morbidity due to stroke. Echocardiography plays a critical role in defining the clinical context of the arrhythmia and guiding management. Transoesophageal echocardiography is used to exclude intracardiac thrombus to facilitate early cardioversion. Emerging technologies such as catheter ablation and left atrial appendage occlusion have expanded the role of echocardiography such that it is essential to achieve a high standard of cardiac imaging to optimize patient outcomes.

The role of echocardiography in guiding management in dilated cardiomyopathy.

Dilated cardiomyopathy (DCM) is a common and malignant condition, which carries a poor long-term prognosis. Underlying disease aetiologies are varied, and often carry specific implications for treatment and prognosis. The role of echocardiography is essential in not only establishing the diagnosis, but also in defining the aetiology, and understanding the pathophysiology. This article therefore explores the pivotal role of echocardiography in the evaluation and management of patients with DCM.

The complete array of electrocardiogram abnormalities secondary to myocardial contusion in a single case.

Myocardial contusion is a complication of blunt thoracic injuries. Transthoracic echocardiography and electrocardiography (ECG) monitoring are important in suspected cases. We report a 54-year-old man, who sustained a number of injuries including blunt chest injury as a consequence of a road traffic accident. Electrocardiography monitoring over a 48 h period demonstrated sequential degrees of conduction system block coupled with a temporary cardio-version from persistent atrial fibrillation to sinus rhythm, suggesting coincident pulmonary vein contusion.

Mitral valve surgery plus concomitant atrial fibrillation ablation is superior to mitral valve surgery alone with an intensive rhythm control strategy.

OBJECTIVE: Prospective randomised study comparing patients with atrial fibrillation (AF) of more than 6 months duration after mitral valve surgery plus biatrial modified radiofrequency Maze procedure using Medtronic Cardioblate System (Cardioblate group, n=24) vs mitral valve surgery plus intensive rhythm control strategy (control group, n=25). METHODS: Patients were blinded to randomisation. Preoperatively, at discharge, and at 3-month and 1-year follow-up, echocardiography, quality of life assessments and ECGs were done. In both groups, sinus rhythm (SR) restoration was attempted by intra- and postoperative DC cardioversion and class III antiarrhythmic medication. All patients received warfarin. Amiodarone and warfarin was considered for discontinuation after 3 months in SR, 24-h Holter or event monitor excluding AF. RESULTS: Both groups underwent mitral valve replacement or repair (Cardioblate vs control: 16:8 vs 10:15), had similar gender (male: 33% vs 56%), age (66+/-8 years vs 68+/-9 years), additional aortic valve replacement (7 vs 6 patients), tricuspid annuloplasty (13 vs 13 patients), and CABG (10 vs 16 patients). There was 0% operative mortality, 0% postoperative cerebrovascular accidents, but 2 late deaths in the control group. At discharge, 3- and 12-month follow-up, more patients in the Cardioblate group returned to normal SR compared to control (29%, 57% and 75% vs 20%, 43% and 39%; p=0.030). Return of functional atrial contraction in patients in SR at 1 year was comparable between groups (63% vs 89%, NS), and more likely in non-rheumatic pathology and preoperative AF of shorter duration. The effectiveness of atrial contraction was 36+/-14% vs 43+/-18% of transmitral flow and there was no difference between groups. Amiodarone treatment decreased more in Cardioblate group over time (92%, 55% and 29% vs 52%, 52% and 21%; p=0.003), whereas warfarin decrease was comparable (100%, 100% and 71% vs 100%, 95% and 82%; NS). CONCLUSIONS: Radiofrequency Maze ablation additional to mitral valve surgery resulted in a higher SR conversion rate (75%), despite control group treatment with intensive rhythm control strategy having a higher SR conversion rate (39%) compared to literature (approximately 25%). Maze ablation resulted in normalisation of atrial function in 63% of patients converted to SR.

Echocardiography in the emergency assessment of acute aortic syndromes.

Acute aortic syndrome (AAS) is a collective term for several life-threatening acute aortic conditions: aortic dissection, intramural haematoma (IMH), penetrating atherosclerotic ulcer, and traumatic transection. Mortality from acute ascending aortic (type A) dissection increases rapidly immediately after presentation, reaching 1-2% per hour for the first 48 h. Early surgical intervention is recommended for type A aortic dissection and has been shown to improve outcome. Transthoracic echocardiography is an extremely valuable, often overlooked, clinical tool in diagnosing and assessing AAS in the emergency setting. Although diagnostic sensitivity is suboptimal, it is very useful in assessing potential high risk features or complications, such as pericardial effusion, and diagnosing potential differential conditions. A negative transthoracic echocardiography (TTE), however, does not exclude AAS. In patients with a high risk of type A dissection or IMH (identified clinically or by TTE), the safest and most rapid 'gold standard' investigation is transoesophageal echocardiography, ideally performed with the cardiac surgical team standing by. This is of particular importance in the haemodynamically unstable patient. Transoesophageal echocardiography, helical CT, and MRI have similar diagnostic accuracy and, when there is diagnostic uncertainty or no indication for immediate intervention, should be used according to clinical need, local availability, and expertise.

The use of contrast echocardiography for the detection of cardiac shunts.

Recently, debate has erupted about the clinical significance of cardiovascular shunts. Several major health problems such as stroke and migraine have been associated with patent foramen ovale (PFO) with right-to-left shunt (RLS). The nature of the relationship between these syndromes and PFO is not clearly understood. Technical advances have led to more therapeutic options including device closure of PFO, hence prevention of such a PFO-related stroke has become feasible. Therefore, optimal diagnosis of PFO has become of greater clinical importance. Contrast echocardiography with non-transpulmonary contrast agents has been the cornerstone in diagnosis of PFO with RLS for over four decades. Despite being a relatively invasive procedure, transesophageal echocardiography (TEE) is considered the gold standard for detection of RLS. Several other echocardiographic techniques such as transthoracic echocardiography (TTE) with second harmonic imaging and transcranial Doppler ultrasonography (TCD) have shown increased sensitivity and specificity compared to TEE for the detection of PFO with RLS. Moreover, improvement of skills and techniques used for detection of these shunts has led to greater detection of small and large sized RLS in the echocardiographic laboratory. This review gives and overview of the echocardiographic techniques, contrast agents and manoeuvres used for detection of the major cardiovascular shunts and their clinical relevance to major health problems.

Quantitation of right ventricular volumes and ejection fraction by three-dimensional echocardiography in patients: comparison with magnetic resonance imaging and radionuclide ventriculography.

Three-dimensional echocardiography (3DE) provides volumetric measurements without geometric assumptions. Volume-rendered 3DE has been shown to be accurate for the measurement of right ventricular (RV) volumes in vitro and in animal studies; however, few data are available regarding its accuracy in patients. This study examined the accuracy of 3DE for quantitation of RV volumes and ejection fraction (EF) in patients, compared to magnetic resonance imaging (MRI) and radionuclide ventriculography (RNV). Twenty patients underwent MRI, gated equilibrium RNV, and 3DE using rotational acquisition from both the transesophageal and transthoracic approaches. RV volumes and EF were calculated from the 3DE data using multislice analysis (true Simpson's rule). RV volumes calculated by MRI (end-diastolic volume (EDV) 109.4 +/- 34.3 mls, end-systolic volume (ESV) 59.6 +/- 31.0 mls, and EF 47.7 +/- 17.1%) agreed closely with 3DE. For transesophageal echocardiography, EDV was 108.1 +/- 29.7 mls (r = 0.86, mean difference 1.3 +/- 17.8 mls); ESV was 62.5 +/- 23.8 mls (r = 0.85, mean difference 2.8 +/- 15.1 mls); and EF was 43.2 +/- 11.7% (r = 0.84, mean difference 4.5 +/- 9.7%). For transthoracic echocardiography, EDV was 107.7 +/- 27.5 mls (r = 0.85, mean difference 1.6 +/- 18.2 mls); ESV was 59.7 +/- 22.1 mls (r = 0.93, mean difference 3.2 +/- 19.6 mls); and EF was 45.2 +/- 11.5% (r = 0.86, mean difference 2.0 +/- 9.4%). There were close correlations, small mean differences and narrow limits of agreement between RNV-derived EF (43.4 +/- 12.1%) and both transesophageal (r = 0.95 mean difference 0.2 +/- 3.7%) and transthoracic 3DE (r = 0.95, mean difference 1.8 +/- 5.4%). Three-dimensional echocardiography is a promising new method of calculating RV volumes and EF, comparing well with MRI and RNV. The accuracy of transthoracic 3DE was comparable to that of the transesophageal approach. Three-dimensional echocardiography has the potential to be useful in the clinical assessment of RV disorders.