newsletter

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 1

ISSUE 71 A f f i l i a t e d t o t h e B r i t i s h C a rd i o v a s c u l a r S o c i e t y

i n c o r p o ra t i n g t h e B S E N E W S L E T T E R

CONTENTS include: Audit of Portable Echocardiographic Studies 6-7 Mechanical Index - relevance to contrast 8 The Role of The Consultant Echocardiographer 9 - 10 NEW GUIDELINES - Suspected Pulmonary Hypertension 11 - 14 CASE REPORTS 15 - 25 BSE at BOURNEMOUTH 19 - 21 2010 AGM Agenda 36

SEPTEMBER 2010

BSE_ECHO_No71 BS Single

PA G E 2

13/9/10

16:58

Page 2

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 3

ECHO ISSUE 71

SEPTEMBER 2010

CONTENTS Page 4 Page 5 Page 6 - 7 Page 8 Page 9 - 10 Page 11 - 14 Page 14 Page 15 - 25 Page 19 - 21 Page 26

Presidents Message Front Cover Audit of Portable Echocardiographic Studies Mechanical Index - relevance to the use of contrast The Role of The Consultant Echocardiographer New Guidelines - Suspected Pulmonary Hypertension Diastolic Dysfunction and Age Case Reports BSE at Bournemouth 3D Speckle Tracking - A New Era for Echocardiography and Myocardial Imaging?

Page 27 ECHO Cryptic Crossword Page 28 - 30 Letters to the Editor Page 31 BSE Accreditation Updates Page 32 - 33 Committee Reports Page 34 2009 AGM Minutes Page 35 2010 AGM Agenda Page 36 Courses Directory 2010/11 Page 37 Departmental Accreditation Log Competition Winner

2009/10 BSE COUNCIL MEMBERS

OFFICERS President: Dr Navroz Masani University Hospital of Wales Immediate Past President: Dr Simon Ray Wythenshawe Hospital, Manchester Honorary Secretary: Jane Allen York District Hospital Honorary Treasurer: Tracy Ryan Cardiac Network liaison for Birmingham, Sandwell & Solihull ELECTED MEMBERS Farhanda Ahmad Heart and Lung Centre, Wolverhampton Dr P Rachael James Royal Sussex County Hospital Dr Graham Leech London Dr Guy Lloyd Eastbourne DGH Dr Ranjit More Chair Accreditation Committee Royal Victoria Hospital, Blackpool Keith Pearce Wythenshawe Hospital, Manchester Dr Helen Rimington St Thomas’s Hospital, London Jude Skipper Queen’s Hospital, Essex Dr Rick Steeds Queen Elizabeth Hospital, Birmingham CO-OPTED MEMBERS (1 year term) Dr Donna Greenhalgh ACTA Representative Wythenshawe Hospital Jane Lynch Wythenshawe Hospital, Manchester Dr Muttucumarasamy Mahendran Primary Care Representative, Milton Keynes Dr Mark Monaghan BHF Liaison, Kings College Hospital Eamon Murtagh SCST Representative Royal Hospital for Sick Children, Glasgow Dr Bushra Rana Papworth Hospital, Cambridge Claire Seal Industry Representative Dr Lindsay Smith Jr Dr Representative, Queen Alexandra Hospital, Portsmouth Dr Gordon Williams

ECHO Editor Leeds General Infirmary

INSTRUCTIONS TO AUTHORS ECHO is published four times per year. It is the official publication of the British Society of Echocardiography the contact address is: BSE Administration, Docklands Business Centre, 10-16 Tiller Road, Docklands, London E14 8PX, Tel. 020 7345 5185, Fax 020 7345 5186 Email admin@bsecho.org. Members of the society are invited to submit articles, case reports or letter correspondence.

Submissions should be to ‘The Editor’, ECHO and forwarded by email to: dr.gordonjwilliams@btopenworld.com and copied to admin@bsecho.org . The format should be text as a normal word document and images in jpeg or bitmap formats.

Articles do not necessarily require text references although important or relevant references are encouraged. References however should be restricted to encouraging further reading and not be comprehensive. References to commence with normally the first two authors, thereafter abbreviate to ‘et al’, then article title, followed by journal reference.

Submissions to ECHO are not peer reviewed. The Editor has discretion on acceptance. Patient consent is required for case reports.

It should be noted that opinions expressed in articles or letters are the opinions of the author(s) and not of the council of the British Society of Echocardiography (BSE). Official BSE council views or statements will be identified as such.

Information in respect of advertisements can be obtained from admin@bsecho.org .

Editor PA G E 3

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 4

MESSAGE

2010. Year on year, the conference has grown in size, content and ambition. This year should be no exception – there is a broader than ever mix of didactic education, interactive casebased sessions, discussions and hands-on workshops. Our previous visit to Bournemouth was a very pleasant experience – it is surprisingly accessible, despite its south coast location, has an excellent conference centre and there is an abundance of social life, the highlight of which is sure to be our party on “Echo Beach”.

The coalition government’s White Paper “Equity and Excellence: Liberating the NHS”, published on 12 July 2010, presents radical changes to the structure of the NHS in England.

(Wales has already undertaken a radically different overhaul of its NHS in 2009-10).

The full programme for the events taking place in Bournemouth are on pages 19-21 and on the back cover you can read about the Vimedix, the simulator company which will be hosting the Satellite session on Thursday evening. Join us there for a buffet and drinks.

An important feature of the White Paper is the proposal to devolve commissioning of clinical services and responsibilities, as well as budgets, to “GP consortia”, in the belief that decision making will thus be made by those who are best placed to act as patients’ advocates, as well as to support them in their decision making. An independent NHS Commissioning Board will provide national leadership on commissioning for quality improvement, patient choice and overseeing aspects of the GP consortia system. The NHS Commission Board will both support GP consortia and hold them to account. In addition, some services, presumably specialist, regional or national services, will be commissioning some services itself.

On page 25 of this edition of ECHO you will see that we are inviting nominations for new members of Council for a three year term. As always the Council is made up of members of the Society, who are active and wiling to be involved in the advancement of echocardiography and BSE as a Society.

People like you. Becoming a member of Council is an ideal opportunity to make sure your voice and local (national) concerns are heard.

PRESIDENT’S

“Liberating the NHS” sees the abolition of the current commissioners - Primary Care Trusts – within the next two years. Relevant to those working in secondary and tertiary services, the Strategic Health Authorities will also be dismantled. A further document, “Commissioning for Patients” provides further details on the intended roles and responsibilities of the GP consortia and NHS Commissioning Board – it also seeks views on a number of specific consultation questions.

Initial thoughts are dominated by the prospect of the major disruption that may ensue in secondary and tertiary care, where most cardiologists and echocardiographers work, as a result of such a radical upheaval. Furthermore, it seems inevitable that the new commissioners will require time to mature and develop, during which prospects of service development or expansion seem slim. It is fair to say that there are equal concerns in primary care, amongst GP’s who will be responsible for developing the new consortia. Specific detailed responses to the consultation document are being prepared by the Royal College of Physicians and the British Cardiovascular Society, amongst many others. BSE is in a position to contribute to the BCS response, through our representation on its Executive.

It is too early to understand the full implications for our Echocardiography departments and the BSE. The roles of professional societies, such as BSE and BCS, as well as the other affiliated groups BCIS, HRUK and PCCS, will include advising the National Commissioning Board (if possible) on quality and standards, to ensure that cost reduction does not override clinical standards. Discussions at BSE Council, as well as BCS Executive, will have taken place by the time you read this, and more detailed analysis and commentary will follow in future editions of ECHO. Comments and opinions are requested from BSE members who have any interest or knowledge of relevance.

If you want to read the full paper, please follow the link on the BSE homepage.

If the prospect of tough times ahead (NHS reform plus public spending cuts are an uninviting prospect) is getting you down, cheer yourself up by finalising your plans to attend this year’s annual BSE Conference in Bournemouth, October 28th-30th, PA G E 4

BSE is not a single entity, it is a collective of all of us and you are encouraged to stand for election, and more importantly, to vote when the online ballot opens.

Enjoy this edition of ECHO, which as usual, has a multitude of interesting articles and case studies, many submitted by members.

I look forward to seeing you in Bournemouth.

Nav

IMEDIX SIMULATORS We are delighted to announce that Vimedix (CAE Healthcare) will be joining us in Bournemouth to host the Satellite session on the evening of Thursday 28th October.

If you will be arriving early in Bournemouth, or staying following the Core Training, FEEL or Accreditation exams, why not join us 19:30 – 21:00?

No registration is required and the session is free to attend. A buffet and drinks will be available to all attendees.

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 5

FRONT COVER There are no prizes for identifying the front cover image of this edition of ECHO. The patent ductus arteriosis is clearly apparent imaged from the super sternal notch. The image identifies the distal aortic arch, the left subclavial artery, the descending aorta and the ductus identified by colour flow. The ductus, an incidental finding in an adult in this case is small, resulting in a minimal increase in pulmonary arterial flow.

In intra uterine life, with no foetal respiration occurring, pulmonary blood flow is not required. The ductus connecting the pulmonary artery to the aorta diverts much of the pulmonary arterial flow to the descending aorta. Within hours of birth and respiration commencing patency of the ductus is no longer required. The ductal tissue constricts occluding it as a vessel thereafter fibrosing there being no longer a vascular connection between the pulmonary artery and aorta. As with most biological systems, normality does not always occur and the ductus can remain open, i.e. a so called patent ductus arteriosus.

With the regression of neonatal pulmonary vascular resistance and the fall of pulmonary arterial pressure, in the presence of the higher systemic vascular resistance, if the ductus remains patent the flow becomes aortic to pulmonary artery i.e. left heart to right heart or simplified to “left to right shunt”. In infants the ductus and its shunt can be large, overloading the right heart, closure of the ductus then being required. Today this can be achieved pharmacologically but may still require surgical ligation or in older children by catheter techniques of plug or occluder device.

pattern. The reasons for this are that a) in most adult studies the colour box is positioned around the pulmonary valve but not extended far enough along the pulmonary artery to detect colour ductal flow which enters near to the pulmonary arterial bifurcation to left and right pulmonary arteries so it is missed, and b) the saw tooth flow pattern which only occurs when there is a significant left to right shunt, so when a small patent ductus exists the diastole pulmonary flow is too small to create that flow pattern.

Additional points to mention in respect of ductal patency relate to anatomical changes with advancing age. The aortic end of the ductus is usually wider than the entrance to the pulmonary artery, that is the ductus is tapered from a larger to a smaller diameter. This creates a venturi effect, accelerating the flow velocity creating a degree of turbulence. As with any other ‘jet’ lesions, the jet turbulence creates a site for the development of endocarditis. Endocarditic vegetations develop at the pulmonary artery end of the ductus and can break off into the lungs resulting in pulmonary abscess formation, hence ductal endocarditis is a grave condition. It is for this reason and not for the degree of shunt that small patent ducts are electively closed. Another age change is that of calcification which occurs in adult patent ducts. Today the persistence of a large ductal shunt is virtually always identified in infancy or childhood it would be extremely rare to find now in an adult but if present could be a cause of pulmonary hypertension.

Having given the above description in respect of patent ducts,

Left subclavian artery

Aorta

Patent ductus

Pulmonary artery

The ductal tissue may partially constrict, resulting in a small shunt, or only a very small unmeasurable shunt. Even a small shunt is usually identified by its typical physical signs, principally that of a continuous or “machinery” murmur on auscultation (running through systole and diastole). It is unfortunately the case that current auscultatory skills are such that this type of murmur may be missed or misinterpreted in an adult hence the presence of a small ductus still being present in adult life may remain clinically undiagnosed.

Echocardiography is the optimum imaging technique to identify the presence of a small ductus.

You may be prompted to look up the echo diagnosis of a patent ductus in a text book and question why I have not described the features conventionally described in paediatric practice. Such features are recognising aortic to pulmonary flow entering the pulmonary artery in a parasternal short axis view and/or not describing the typical “saw tooth” spectral Doppler flow

whilst they do exist in the adult population they are rare.

Additionally there occasionally occurs a recannulised ductus, which happens when a childhood ductus which has been surgically ligated (but not divided) has not been completely tied off leaving a small way through (this is today a rare occurrence).

However for those of you who may practise veterinary ultrasound, patent ducts are relatively common in certain breeds of dog, notably Poodles, Collies and Shetland sheep dogs.

There is some evidence of an inherited trait in these dogs although inheritance in humans is not clear but an incidence of 3% is said to occur in siblings of those with patent ductus.

Purely out of interest patent ducts are also relatively frequently found in pigeons and pigs!

Although uncommon, it adds to the interest when a rarity is detected.

Gordon Williams, Editor PA G E 5

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 6

AUDIT OF PORTABLE ECHOCARDIOGRAPHIC STUDIES Introduction The use of portable echocardiography has been validated as part of community screening programmes and as a “point of care” diagnostic tool in acutely ill patients.

Portable echo can provide basic diagnosis in the vast majority of patients. This includes the assessment of pericardial effusions, the measurement of the dimensions of cardiac chambers, the identification of valvular pathology and the assessment of ventricular function.

Portable echocardiography has the same limitations as standard echo (e.g. difficult windows in patients with airways disease or the severely obese). In addition many of the patients that are too unwell to travel to the Echocardiography department represent an added challenge to the echocardiographer (e.g. not possible to rotate patients on ventilators into a lateral position and surgical incisions and dressings may obscure precordial or apical windows).

Despite this, and when performed by experienced operators, the sensitivity of portable echocardiography for the detection of cardiac pathology is higher than that of clinical examination and can reach 70-90% when compared with standard departmental studies.1

Methods All echos carried out using the portable machine (Siemens X 300) between 03/02/2010 and 26/02/2010 were audited. The studies were then uploaded to the hospital’s echocardiography images management and reporting system (PROSOLV, FUJIFILM Medical Systems U.S.A., Inc.). They were then analysed in the department by either a consultant in cardiology with a special interest in imaging or by the principal echocardiographer. The reports were retrospectively collected from the clinical notes and reviewed in the department.

Results A total of 73 studies were initially identified. 24 were not included for several reasons: 3 were excluded as no patient details inserted with the study; in 4 cases no images were saved in the machine; in 7 no report was found in the clinical notes; for 10 studies the clinical notes were not available during the audit period as patients had been transferred to other hospitals.

Therefore only 49 studies were fully reviewed and included in the audit.

80% of studies were carried out by Cardiology SpRs (39 / 49).

16% of studies performed by SHOs (8 / 49) and 4% carried out

by SHO under supervision of SpR (2 / 49).

As expected the majority of studies were performed in the Coronary Care Unit and in the Cardiology ward.

A Portable “focused study” limits the examination to answering a specific question determined by the clinical context. Even these limited examinations require substantial training and should preferably be performed by accredited individuals in order to avoid diagnostic errors. To illustrate this point a study based in a north-American ITU indicated that up to 31% of important findings were missed by portable echo when compared to standard studies.2 The American College of Cardiology/American Heart Association/ American Society of Echocardiography3, the British Society of Echocardiography4 and the European Association of Echocardiography5 have all produced recommendations on training requirements. They have identified the minimal training that is considered necessary to achieve the skills for performance according to accepted standards. Accreditation is however “a minimum requirement and cannot be regarded as a guarantee of competence”.

Accreditation tends to consist of log books of studies (150 to 250) and practical and written assessments. Current recommendations maintain that echocardiographic studies performed by inexperienced clinicians should not be used to influence the management of patients.

Figure 1. Location of Portable studies Indications for the echo varied widely. The major groups include patients that had suffered an acute Coronary Syndrome or were post-STEMI. The third largest patient group included patients admitted for an urgent inpatient CABG procedure.

Aims We conducted an audit of Portable Echocardiographic Studies undertaken at a large cardiology tertiary referral centre in London. We aimed to quantify the number of studies being carried out outside the echocardiography department and to identify the indication for portable scanning. The quality of images obtained and the quality of the reports being issued were then retrospectively analysed. We aimed to prompt reflection on current clinical practice and to facilitate continuous quality improvement.

PA G E 6

Figure 2. Indications for Portable Echocardiography

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 7

Conclusion

The quality of the images obtained for the studies were then ranked from A (illustration quality) to F (non-diagnostic studies):

This audit identified several relevant issues from a clinical governance point of view.

Assessment of Images Obtained Quality A All valves of illustration quality, 100% of endocardial definition , all windows of illustration quality

4%

Quality B All valves clearly defined, 100% of endocardial definition; at least one window of illustration quality

4%

Quality C All valves well defined, > 70% of endocardial definition, all windows obtained of diagnostic quality

41%

Quality D One ill-defined valve and/or >50% of endocardial definition; at least one non-obtainable window 8% Quality E Two ill-defined valves and/or <50 % of endocardial definition; at least two non-obtainable windows 39% Quality F Study Non-diagnostic

4%

Figure 3. Assessment of Images Obtained The reports issued at the time were also ranked from category 5 (No disagreement) to category 1 (Definite omission or misinterpretation with unequivocal potential for serious morbidity or threat to life): Departmental Assessment of the Report Issued Category 5 No disagreement

31%

Category 4 Disagreement over style or presentation of the report including failure to describe clinically insignificant features 24% Category 3 Clinical significance of disagreement is debatable or likelihood of harm is low 22% Category 2 Definite omission or interpretation of finding with strong likelihood of moderate morbidity but no threat to life ?

18%

Category 1 Definite omission or misinterpretation with unequivocal potential for serious morbidity or threat to life 0% Non-diagnostic Studies

4%

None of the audited echos had been uploaded to the hospitalwide echocardiography database system and could not therefore be easily reviewed by the medical staff making decisions about patient management. Since this audit was presented the technical issues related to the uploading of images have been resolved and this now happens routinely and automatically.

In 7 out of the 73 studies initially identified no report was found in the notes. This raised the question of some studies not being formally reported. At a departmental meeting, where this audit was presented, the SpRs and SHOs were reminded that any echo assessment (even “quick look” scans) that affects patient management must be recorded and reports documented in the notes.

Analysis of the data collected allows us to conclude the following: 49 % of all studies (24 / 49) of quality A, B, or C all valves visible and studies of diagnostic quality. The quality of studies in this audit falls below departmental standard (39% of scans of Quality E - Two ill-defined valves and/or <50 % of endocardial definition and/or at least two non-obtainable windows) but the patient population is more challenging (e.g.

8% of patients in ITU, 15% post cardiothoracic surgery, many acutely unwell).

The quality of reporting was generally good with 77 % (38 / 49) of reports of category 3, 4 or 5 (No or minimal disagreements with original report). No gross errors in reporting were identified. However 18% of reports (9 / 49 echos) had reports of Category 2 (definite omission or misinterpretation of findings with strong likelihood of moderate morbidity but no threat to life). This highlighted the need for scans to be discussed with an expert where any doubt remains. If necessary scans should be repeated and if possible be carried out in the department. The Cardiology registrars were also encouraged to issue computerised reports of the portable studies. These should be done in the Echo department where a second opinion and feedback can easily be obtained.

Following our recommendations a registry of all the portable scans that are carried was started. This will facilitate continuous audit and assessment and is a practise we recommend to all users of portable echo.

Dr. Antonio de Marvão, Professor Petros Nihoyannopoulos Hammersmith Hospital, London References 1 Ashrafian H, Bogle RG, Rosen SD, et al. Portable echocardiography. BMJ. 2004 Feb 7;328(7435):300-1 2 Goodkin GM, Spevack DM, Tunick PA, Kronzon I. How useful is hand-carried bedside echocardiography in critically ill patients J Am Coll Cardiol 2001;37: 2019-22 3 Quinones MA, et al. ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians. J Am Coll Cardiol 2003;41:687–708.

4 British Society of Echocardiography. Accreditation. http://www.bsecho.org/index 5 European Society of Echocardiography. http://www.escardio.org/communities/EAE/accreditation/TTE

Figure4. Departmental Assessment of the Report Issued PA G E 7

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 8

MECHANICAL INDEX – and the practical relevance to the use of contrast

Where PNAP = peak negative acoustic pressure and MI = Mechanical Index.

In other words MI is directly proportional to PNAP and inversely to the square root of transmitted frequency.

In addition to displaying the M.I., current equipment allows the operator to control power (M.I.) up or down. Increasing the M.I. will give more penetration and improve resolution (but the level of M.I. used should be balanced to give the optimum information with no point in increasing it higher than the optimum image).

Here is a practical feature, when using contrast imaging you may have noticed that if you change the frequency you can significantly change the contrast image, the reason being that if e.g. you decrease the frequency it results in more power (i.e. a higher MI) with increased contrast destruction.

With transpulmonary contrast now part of everyday life for the echocardiographer, it is common knowledge that the ultrasound ‘power’ otherwise known as the ‘mechanical index’, has to be turned down to optimise contrast enhanced images. Why? If the transmitted acoustic power is very low, the returning signal after hitting ultrasound contrast bubbles is similar to the transmitted. If the signal power is turned up a little, to a low setting perhaps 0.10MI (mechanical index), the bubble is excited and oscillates non linearly resulting in the return of the fundamental frequency and a second harmonic signal. If the power is turned higher the returning signal is the fundamental together with several harmonic signals. Finally, if the transmitted power is turned even higher the contrast bubbles are agitated to such an extent that their capsule bursts and the contrast signal enhancement benefit lost (often recognised as contrast ‘swirling’).

In practise then, adjusting ultrasound power is essential for the diagnostic benefit of contrast to be optimised.

Given that ultrasound or acoustic power is given in terms of Mechanical Index, what exactly is ‘Mechanical Index’?

Ultrasound waves are generated by the electrical excitement of a piezo electric crystal the oscillation of the crystal transmitting waves into tissue and awaiting their return to descramble then back into electrical signals. Think of the waves as pressure waves even though they are termed ultrasound waves (as that term just describes the frequency of the waves). The transmitted waves have a positive and negative pressure component (as per Fig 1). As the waves traverse body tissue they cause some heating or temperature rise of that tissue, referred to as the “thermal index” of the transmission. The positive and negative pressure waves move the tissue components and therefore cause a mechanical change referred to as the “mechanical index” of the transmission. The combined indices are referred to as “acoustic output”. The situation is always somewhat more complicated than a brief description allows as peak positive and negative ultrasound pressures can vary with different modes of ultrasound e.g. a single Mmode line or a wider real time sector with differing frequencies of transmission, pulse repetition and pulse duration. “Thermal index” is of little concern in echocardiography compared to other types of diagnostic ultrasound in that it is considered that the blood traversing the cardiac chambers and myocardium acts as a cooling agent. It is more applicable to scanning static structures. With high mechanical acoustic pulses i.e. repetitive positive and negative pressure pulses theoretical tissue damage can occur referred to as acoustic cavitation.

Usually in tissue there is some naturally occurring cavity or space, however minute, for cavitation to develop. Interest has been mainly concentrated on the negative component of the pressure wave of the transmitted pulse as the ‘negativity’ or ‘suction’ can result in causing or creating ‘cavities’ or enlarging cavities in tissues and consequently cause tissue damage by further “cavitation”.

Most of the scientific evidence for inducing tissue damage comes from animal experiments e.g. recognising extravasation of blood from mouse lungs which occurs with an M.I. of in excess of 0.6 M.I. Interestingly when I looked up more of this type of research on the harmful effects of ultrasound it had been demonstrated on insects, fruit flies (whatever they are) and so called “lower animals”. It seems that if some cavitation already exists then the acoustic pressure of ultrasound will be more easily detrimental. Anyway, all the theory has been interpreted to impose an upper limit on “Mechanical Index” (M.I.) for diagnostic ultrasound of 1.9 as exceeding it may become close the threshold for tissue damage.

What the outputs were up until 1976 I haven’t found listed, as it is not the data manufacturers would then publish however it is now accepted as a requirement that echocardiographic equipment displays the output as the “mechanical index”. Unless you are really into physics I doubt if anyone can remember in the long term the definition of “mechanical index” so here goes, it is “the derated peak rerefractional pressure in megapascals (1 Mpa being approximately 10 atmospheres) at the point of maximum pulse intensity integral, divided by the square root of the ultrasonic centre frequence in Megahertz” – so there PA G E 8

MI =

PNAP

The relationship can be simplified to

√ frequency

+ Ve

A m p l i t u d e

P r e s s u r e PNAP - Ve

Fig 1. Depicting the transmitted ultrasound signal as a positive and negative pressure wave.

Returning to the negative pressure component of the transmitted signal and its direct relationship to power (MI) whereby the negative pressure results in creating cavities it can now be clearly seen how high imaging power increases bubble oscillation and expands their cavity until the shell or capsule of the contrast bursts or collapses. The experimental work 30 years ago (before gasses were encapsulated to form imaging contrast bubbles) observing how transmitted ultrasound “blew up” or exploded insects or fruit flies by expanding their cavities now has relevance and makes increasing contrast bubble cavities until they blow up and are destroyed hardly surprising and very understandable.

Contrast agents with diatomic gases (e.g. air, O2, nitrogen) are more vulnerable than larger molecules (e.g. CO2 or fluorocarbons) as they are more prone to violent cavitation in a given acoustic field (although there is the additional effect of the bubble shell or capsule which can influence this). Thus in addition to size, imaging contrast bubbles are filled with fluorocarbons and not air for stability to enable them to remain intact for long enough to traverse the lungs What may have appeared irrelevant research blowing up fruit flies years ago has now come to fruition and is very relevant to current ultrasound contrast imaging.

I will write a further related article building on the above information describing high and low MI imaging, power modulated imaging and other related but often confused terms in a subsequent edition of ECHO. Gordon Williams Editor

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 9

THE ROLE OF THE CONSULTANT ECHOCARDIOGRAPHER The concept of a Consultant Echocardiographer is not well recognized in NHS Trusts across the country. Raising awareness of this important and much needed new role is essential to improve career development for echocardiographers who wish to pursue an academic and purely scientific career as an alternative to management to reach the top of the career ladder.

Such posts require individuals to deliver specialist clinical services, which exceed existing grading criteria and cannot be appropriately rewarded or recognised under the current grading structure. In the technically challenging and rapidly expanding field of echocardiography these posts should improve the quality in echo service provision and contribute to education and echocardiography research.

Background In1998 and the labour government were in power. The Prime Minister Tony Blair first described the concept of a nurse consultant and announced a national strategy for consultation into developing this new job profile. He announced that this was a “career opportunity for expert, highly experienced nurses who wished to remain in clinical practice.”

The first nurse consultant posts were funded by the Department of Health in 1999 and were appointed in England in January 2000. Further nurse consultant appointments in Northern Ireland in September 2000 followed an announcement from the minister of health, social services and public safety stating “The establishment of these groundbreaking posts will help develop our health services and provide clear development opportunities for nurses. For the first time, nurses can keep up their day-today contact with their patients, in wards and in the community, and yet still progress in their careers.” April 2001 saw the appointment of nurse consultants in Wales.

In 2004 the first consultant posts in the Allied Healthcare Professions were appointed and included radiography, radiotherapy, physiotherapy, speech therapy and dietetics, all state registered professions . The first breakthrough for nonregistered healthcare professionals in clinical cardiac physiology came in 2006 to echocardiography , with the appointment of the first Consultant Echocardiographer in Leeds. Currently there are less than a handful of such posts in the United Kingdom.

Training as a Consultant At present, postgraduate diploma, MSc or PhD level academic education, professional education and training plus at least 5 yrs post qualifying experience are an essential requirement and the gateway for a consultant post. For those without this prerequisite qualification other factors may be taken into account such as recognition by peers, length of clinical experience, personal qualities, professional activities and status.

In the near future modernising scientific careers will support achievement of this level of academic education by following a specific career pathway. This allows entry point at a registered healthcare scientist level with competitive entry on to higher specialist scientist training leading to a MSc qualification. Like cardiologist or other consultant posts , these consultant posts will be competitive and can be applied for only after completion of this training.

Modernising Scientific Careers Clinical Cardiac Physiology is one of 51 disciplines in the Healthcare Science Workforce that is being modernised and is under scrutiny for state registration. The DoH have recognised the importance of the Healthcare Science Workforce which constitutes 5% of the total healthcare workforce in the UK. Almost 80% of all diagnoses made are a result of their work. In modernising the health service the DoH have recognised the importance of the consultant healthcare scientist role which will provide: • Clinical and scientific expertise .

• Consultant level advice within the context of direct patient care.

• Give strategic direction, innovate and provide highly developed and specialised skills for service development and provision.

• Initiate or lead formal research activities, innovation & improvement.

• Lead education and training activities.

Funding the Consultant Post.

Once a trust has identified and established a need for a consultant post and found the funding then the post has to be approved by a panel of experts at the strategic health authority.

This panel may include the following representatives: • An expert from the specialist area • Educational representative • Patient/Public representative • Service Director/Manager • Professional body representative • Nurse Director/Manager • Research & Development representative • Workforce Development Unit representative.

The submission to the strategic health authority should include • A covering letter giving details of the specific nature of the post, which should also include contact information for particular organisations and the proposer.

• Background information in support of the development of the post including, policy content, health needs assessment, key stakeholders and strategic partnerships, impact on patient care, service development , links with regional networks such as cardiovascular/cancer/diabetes etc.

• A draft job description, person specifications and job plan including clinical practice.

• Education/research funding.

• Risk Assessment.

• Management/support structures and lines of accountability.

• A provisional assessment of salary.

• A timetable and details of the appointment process.

• Confirmation of agreed recurrent funding from NHS Board and /or other partner organisations.

Core Functions of The Consultant Role On the National Framework there are 4 Core Functions that exemplify the consultant role to achieve quality service provision and better outcomes for patients: 1) Expert Clinical Practice 2) Education and Professional Development 3) Research, Audit and Evaluation.

4) Leadership PA G E 9

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 10

Expert Clinical Practice Function • Provide consultancy –patient level, service level, regional/national level • Approx 50% of time working directly with patients.

• Develop and deliver new specialist services such as physiologist led DSE, TOE, Contrast etc • Develop clinical expertise of staff • Use expertise in an enabling and empowering way • Modernising Services -lead change in how services are delivered • Business minded.

• Innovative and Creative • Knowledge of patient pathways • Manages change Education and professional development • Lead development of learning culture • Support service development • Continued professional education • Share skills with others • Influence design and development of national / international professional education Research, Audit and Evaluation • Lead the selection and design of research and audits • Putting ideas into practice • Reflective practice • Dissemination of findings Strategic and Professional Leadership required for all core functions • Communicate a vision for the service • Collaborate and influence • Deliver change - interpersonal skills and intellectual effort is essential to deliver change.

• Leadership processes include exerting control over complex change initiatives. Requires confidence, courage, resilience, risk-taking.

• Ensuring visibility at both local and national level.

Benefits of a Clinical Career • Allows progression in a clinical career with academic and financial recognition.

• Opportunity to utilise high quality research evidence to inform current practice for the development and improvement of service delivery .

• Working in partnerships in different ways to take new initiatives forward.

• Develop and apply leadership skills to engage in innovative and exciting research projects. Freedom to pioneer and cross boundaries.

• Breaking new ground.

• Personally higher job satisfaction • Opportunity to make a difference to your profession.

• Achieving set goals • Personal rewards Difficulties and Challenges of a Clinical Career • Difficult to change practice in some areas due to lack of a high quality research base.

• Dealing with colleagues and managers that may not value research evidence as reason to change practice • Lack of own research and development skills.

PA G E 10

• Keeping up to date with central policy initiatives and taking them into account when developing new services • Resistance to change • Scepticism-achievement and acceptance of the consultant role.

• Demanding-work overload therefore need to set boundaries to job description and not take on too much.

• Facing Challenges • Loneliness and fear of failure There is no national research data about the effectiveness of the role of the Consultant Echocardiographer . A personal evaluation suggests that this role needs to happen for the right reasons and not just to meet personal aspirations. Such a role should stem from service need and aim to fill gaps in echocardiography service provision. It should not be used as a cost-saving exercise to replace the consultant cardiologist with specialist interest in Echocardiography. A supportive nurturing environment is important to ensure success of the post.

Professional and personal support are mandatory because due to the innovative nature of the role there is risk of isolation. The role is beneficial to echo service development as it provides a readiness to cross traditional boundaries in echocardiography practice as well as education. For the post holder it provides increased job satisfaction, strengthens leadership within the profession, provides an opportunity to make a difference to the profession, achieve set goals and is personally rewarding.

Consultancy is not a “matter of chance it is a matter of choice, it is not to be waited for, it is something to be achieved.”

Fay Ahmad Consultant Echocardiographer References • British Cardiac Society. Cardiac workforce requirements in the UK, April 2004. www.bcs.com/download/221/BCSCardiac-Workforce-2004.pdf • Department of Health (2000) “Alan Milburn announces first nurse consultant posts”, www.dh.gov.uk • Department of Health (2001) “Empowering the frontlinemore NHS nurse consultants”, www.dh.gov.uk • Department of Health (2000) “Health secretary announces ninety-one new nurse consultant posts”, www.dh.gov.uk • Dewing, J. (2003) “A mode24/05/2010 15:28l for clinical practice within the nurse consultant role”, Nursing Times, Volume 99, No. • Fifth report on the provision of services for patients with heart disease. Heart 2002;88(Suppl 3):iii1–56. 76 • Lipley, N. (2000) “Survey finds consultant nurse posts hard to fill”, Nursing Standard, Volume 15, No.2 • Manley, K. (1997) “A conceptual framework for advanced practice: an action research project operationalising an advanced • McKenna HP, Cutcliffe JR, McKenna P. PhD or DNSc: What contribution to the substance of Nursing? All Ireland Journal of Nursing & Midwifery; Vol 1, No 2, 55-58 • Modernising Scientific Careers http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalass ets/@dh/@en/@abous/documents/digitalasset/dh_113200.pdf • Office of the Chief Nursing Officer, Welsh Assembly Government, (2003) “Evaluation Tranche 1Nurse/midwife/health visitor consultant posts“ • Practitioner/Consultant role”, Journal of Clinical Nursing, Volume 6, 179- 190

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 11

NEW GUIDELINES A Guideline Protocol for the Assessment of Patients with Suspected Pulmonary Hypertension.

From the British Society of Echocardiography Education Committee David Dawson, Julia Grapsa, Petros Nihoyannopoulos (Lead Authors) Richard Steeds (Chair), Nicola Smith, Julie Sandoval, Gill Wharton, Jane Allen, Prathap Kanagala, John Chambers, Richard Jones, Thomas Mathew, Richard Wheeler, Guy Lloyd

1. Introduction 1. 1 The BSE Education Committee has previously published a minimum dataset for a standard adult transthoracic echocardiogram, available on-line at www.bsecho.org. This document specifically states that the minimum dataset is usually only sufficient when the echocardiographic study is entirely normal. The aim of the Education Committee is to publish a series of appendices to cover specific pathologies to support this minimum dataset.

1.2 The intended benefits of such supplementary recommendations are to: • Support cardiologists and echocardiographers to develop local protocols and quality control programs for adult transthoracic study • Promote quality by defining a set of descriptive terms and measurements, in conjunction with a systematic approach to performing and reporting a study in specific disease-states • Facilitate the accurate comparison of serial echocardiograms performed in patients at the same or different sites.

1.3. This document gives recommendations for the image and analysis dataset required in patients being assessed for suspected pulmonary hypertension. The views and measurements are supplementary to those outlined in the minimum dataset and are given assuming a full study will be performed in all patients.

1.4 When the condition or acoustic windows of the patient prevent the acquisition of one or more components of the supplementary Dataset, or when measurements result in misleading information (e.g. off-axis measurements) this should be stated.

1.5 This document is a guideline for echocardiography in the assessment of patients with suspected pulmonary hypertension and will be up-dated in accordance with changes directed by publications or changes in practice.

PA G E 11

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 12

VIEW

Modality Measurements

Explanatory Note

PLAX

2D

RV:LV ratio cutoff >0.5:1

RV:LV Diastolic Ratio • Qualitative

• Significance: Diagnostic • An assessment of RV enlargement

• Identify pericardial effusion as a marker of adverse prognosis

A4CH

2D

RV Minor/Major Axis Dimensions (RVd)

• See BSE Guidelines: Chamber Quantification • Significance: Diagnostic • An assessment of RV size and function

• Quantitative RV Diastolic and Systolic Area (RVAd/s) • Quantitative— calculate Fractional Area Change1

A4CH

M-mode Tricuspid Systolic Annular Plane Excursion (TAPSE) • M-mode cursor across lateral tricuspid annulus • Select a fast sweep speed.

• Measure total excursion of the tricuspid annulus

PSAX

• See BSE Guidelines: Chamber Quantification • Significance: Diagnostic • A measure of longitudinal RV systolic function2

Inferior Vena Cava See BSE Guidelines: Chamber 2D Quantification M-mode Diameter (IVC) • At end diastole and end-expiration.

• Perpendicular to the IVC long axis.

• Approx1.0 – 2.0 cm from the RA junction.

• Assess % reduction in diameter with sniffing.

PA G E 12

TAPSE cutoff <1.6 cm

• Significance: Diagnostic & Prognostic • Indicator of RV filling pressure • Consider assessing hepatic vein flow to supplement accuracy3

Image

BSE_ECHO_No71 BS Single

A4C PSAX

13/9/10

CW

16:58

Page 13

Peak tricuspid regurgitant velocity (TR Vmax)

TR Vmax cutoff >2.6 m/s >2.8 m/s if obese >2.9 m/s if >60 yrs • Significance: Diagnostic4 • A indicator of pulmonary pressure in the absence of pulmonary stenosis • Consider agitated saline/air/blood contrast if incomplete envelope 5

PSAX

PW

RV outflow tract acceleration time (AT)

RVOT AT cutoff <105 ms • Significance: Diagnostic 6 • Surrogate measure of PA pressure

Held end-expiration Onset of flow to peak velocity

A4CH

PW TDI

Isovolumetric relaxation time (IVRT) • Sample volume at basal lateral RV myocardium • Held end-expiration • Offset of S’ wave to onset E’ wave

PSAX

2D

Eccemticity Index (EI) EI = D2/D1 Where: D1 = Minor axis dimension perpendicular to septum

RV IVRT cutoff >75 ms • Significance: Diagnostic. A value below 40ms has a high negative predictive value for PHT 7 • A measure of RV dysfunction.

EI cutoff >1.0 • Significance: Prognostic 8 • EI end systole an expression pressure overload • EI end diastole an expression volume overload

D2 = Minor axis dimension perdendicular to D1

A4CH

2D

RA Volume (RAV)

RAVI male cutoff >33 m/m2

Where: RAV=0.85(A2)/L

RAVI female cutoff >27 ml/m2 • Significance: Prognostic 9

PA G E 13

BSE_ECHO_No71 BS Single

A4CH

13/9/10

PW TDI

16:58

Page 14

RV S’ Wave Velocity • Sample volume at basal lateral RV myocardium

A4CH

PW TDI

S’ wave velocity cutoff : <12 cm/s • Significance: Diagnostic 10 • Expression of RV longitudinal systolic function

RV MPI

• RV MPI cut off: >0.32

MPI= a-b/b

• Significance: Prognostic 11 • Expression of RV systolic and diastolic performance

Where: a = A’ offset to E’ onset b = S’ onset to S’ offset

References 1. Ghio S, et al. Prognostic relevance of the echocardiographic assessment of right ventricular function in patients with idiopathic pulmonary arterial hypertension. Int J Cardiol 2008;140:272-280.

2. Forfia PR et al. Tricuspid annular displacement predicts survival in pulmonary hypertension. Am J Respir Crit Care Med 2006;174:1034-1041.

3. Brennan JM, et al. Reappraisal of the Use of Inferior Vena Cava for Estimating Right Atrial Pressure. J Am Soc Echocardiogr 2007;20:857-861.

4. McQuillan BM, et al. Clinical correlates and reference intervals for pulmonary artery systolic pressure among echocardiographically normal subjects. Circ 2001;104:2797-2802.

5. Jeon DS, et al. The Usefulness of a 10% Air-10% Blood-80% Saline Mixture for Contrast Echocardiography: Doppler Measurement of Pulmonary Artery Systolic Pressure. J Am Coll Cardiol 2002;39:124-129.

6. Kitabatake A, et al. Noninvasive evaluation of pulmonary hypertension by a pulsed doppler technique. Circ 1983;68:302-309.

7. Brechat N, et al. Usefulness of right ventricular isovolumic relaxation time in predicting systolic pulmonary artery pressure. Eur J Echocardiogr 2008;9:547-554.

8. Ryan T, et al. An echocardiographic index for separation of right ventricular volume and pressure overload. J Am Coll Cardiol 1985;5:918-927.

9. Raymond RJ, et al. Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension. J Am Coll Cardiol 2002;39:1214-1219.

10. Melek M, et al. Tissue Doppler evaluation of tricuspid annulus for estimation of pulmonary artery pressure in patients with COPD. Lung 2006;184:121-31.

11. Yeo TC, et al. Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. Am J Cardiol 1998;81:1157-1161.

DIASTOLIC DYSFUNCTION AND AGE The following query was posted on the BSE web forum.

At what point do we comment on mild diastolic dysfunction?

I currently comment that mild diastolic dysfunction may be considered normal for age if a patient is >55yrs.

Would this be considered correct? Or should we disregard age?

And also, if there are structural changes associated with mild diastolic dysfunction such as LA dilatation or aortic root dilatation/loss of geometry, should we consider that this is abnormal regardless of age?

My main concern is labelling patients as having diastolic dysfunction on reports for consultants who are not cardiologists or who may not understand the implications of the age factor.

Response About half of patients with a new diagnosis of heart failure have normal or near normal global ejection fraction. These patients are diagnosed with ‘diastolic heart failure’ or ‘heart failure with preserved ejection fraction’. The assessment of diastolic function and filling pressures are integral to the diagnosis of this condition and echocardiography is the principal non invasive clinical tool used for this purpose.

Over the past 25 years, multiple echo parameters have been proposed for the assessment of diastolic function each with its strength and limitations. These measurements can also be used PA G E 14

to grade the severity of diastolic dysfunction into mild or Grade I (impaired relaxation pattern), moderate or Grade II (pseudo normal filling pattern) and severe or Grade III (restrictive filling pattern). However many of these echo parameters are influenced by heart rate, age and loading conditions and must be taken into consideration during evaluation.

Normal aging alters the diastolic properties of the left ventricle resulting in abnormal relaxation and compliance. In turn, several of the echo parameters used to assess diastolic dysfunction also change with age. Differentiating these age related changes from mild or Grade I diastolic dysfunction (where the LV filling pressures are commonly raised at rest or with exercise) requires a comprehensive 2D, spectral and tissue Doppler evaluation and using age related cut off values.

Although this process is tedious, the distinction is clinically important as the 5 year mortality in a patient with mild diastolic dysfunction even in the absence of symptoms is five-fold higher than in subjects with normal diastolic function. Therefore labelling some one with mild diastolic dysfunction simply based on age or a reversed E/A ratio without taking into consideration other parameters is not recommended. No single parameter can be used in isolation. A guideline outlining this and the data set required to assess diastolic dysfunction is being developed by the BSE and will be published in a future copy of Echo.

Dr. Thomas Mathew, Nottingham University Hospital on behalf of the Educational Committee of British Society of Echocardiography

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 15

CASE REPORTS 1) Incidental finding of inferior venacaval tumour with thrombus A 57 year old lady presented to accident and emergency department with dizziness. She was subsequently referred by her GP for an echocardiogram to the open access clinic for investigation of an asymptomatic murmur. Echocardiography

A right total nephrectomy with removal of the IVC tumour using a sternotomy and extended hockey stick incision was performed. She required pericardiectomy and liver mobilisation but did not require cardiopulmonary bypass.

This case report highlights the need to perform a complete echocardiogram examination in all cases to pick up significant incidental findings that may have a bearing on patient management.

Fig. 3a.

Fig. 1. Subcostal view showing tubular mass arising in the IVC extending into the right atrium. revealed no significant valve lesions. On sub-costal and apical views a tubular mass was seen within the IVC and protruding into the right atrium (Figures 1 & 2). The IVC was dilated to 3 cm. There were no signs to suggest pulmonary embolism.

Computed Tomography (CT) scan showed a large mass at the upper pole of right kidney with extension of tumor from the right renal vein and IVC to the IVC-RA junction (Figure 3) She was diagnosed to have renal cell carcinoma with IVC tumor extending into the right atrium.

Fig. 3b.

Fig. 3. CT scan a. Coronal section showing filling defect in the IVC extending up to the right atrium. b. Transverse section at the level of the kidneys showing the renal tumour and filling defect in the IVC which represents a tumour thrombus.

Renal cell carcinoma is the commonest tumour known to spread to the IVC. When the tumour extends into the IVC, blood in the form of thrombus adhers to its surface, the resulting mass detected by echo is a complex of tumour and thrombus. The management of renal cell carcinoma (RCC) with IVC tumour thrombus is difficult in clinical practice. Complete surgical removal of the primary tumor with its extension along the IVC is recommended if feasable. The diagnosis of vena caval invasion, especially the determination of tumor thrombus extension, is important for surgical planning. Cardiac involvement requires a cardiothoracic surgical approach usually with cardiopulmonary bypass. CT remains the most appropriate imaging modality to differentiate benign from malignant renal lesions. For vena caval or intracardiac involvement an MRI examination is advisable.

Dr. Sujata Khambekar, S. Khambekar, C Peebles, D Rakhit Southampton General Hospital References:

Fig. 2. Apical 4 chamber view showing extension of the IVC

1. Preoperative imaging in renal cell cancer. Heindenreich A, Ravery V; World J Urol. 2004 Nov; 22(5):307-15.

tumour in to the RA. PA G E 15

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 16

2) Intracardiac pseudotumour: a case of caseous calcification of the mitral annulus An 81 year old female presented with shortness of breath and was found to be in atrial fibrillation with significant mitral regurgitation. The past history included ongoing treatment for hypertension. A transthoracic echocardiogram demonstrated a large mass in the region of the mitral valve (Figure 1). This projected into an enlarged left atrium and was associated with both significant mitral regurgitation and left ventricular outflow tract obstruction. A computerised tomographic (CT) scan confirmed this mass to represent circumferential calcification of the mitral annulus. On CT imaging, the structure appeared as an ellipsoid shape with a calcified rim. Within this mass, high and low density regions were identified. It did not enhance on postcontrast CT acquired imaging.

Mitral annular calcification is relatively common in the elderly and, for reasons yet unexplained, is predominantly seen in

women. When the calcification is more extreme, a rare variant occurs, termed caseous calcification. One of the largest studies published, reported on 14 patients with caseous mitral valve calcification; all 14 were elderly and all hypertensive [1]. In some reports the calcification is described as extending into the myocardium with resultant dysfunction of the subvalavular apparatus and a restrictive cardiomyopathy.

As in this case there is usually a rim of calcium with central echo lucencies suggestive of liquefaction. When associated with mitral valve dysfunction, cardiac surgery to excise the mass and replace the valve, with or without ring annuloplasty, has to be perfomed. At surgery, the interior of such structures have been found to contain a â&#x20AC;&#x2DC;putty likeâ&#x20AC;&#x2122; caseous material [2]. A surprising feature of this condition includes occasional reports of spontaneous resolution [1].

Interestingly, similar features of caseous calcification occuring on the tricuspid valve annulus are far rarer than those on the mitral annulus.

The features of caseous calcification of the mitral valve annulus are important, in order to avoid diagnostic confusion with thrombus, an enlarged coronary sinus, tumour or abscess.

Whilst a benign condition, the physical presence of a large mass has significant implications to the functioning of the mitral valve. Cardiac CT scanning not only helps diagnose such an intra-cardiac mass, but also to assess its influence on adjacent structures.

Dr Simon Dubrey, Dr Simon Pearse, Dr Maher Dahdal, Dr Richard Grocott-Mason Hillingdon Hospital NHS Trust Dr Tarun Mittal Royal Brompton and Harefield NHS trust References 1.Deluca G, Correale M, et al. The incidence and clinical course of caseous calcification of the mitral annulus: a prospective echocardiographic study. J Am Soc Echocardiogr 2008;21(7):828-833.

Fig. 1. Transthoracic echocardiographic parasternal view showing a spherical mass (4.8cm x 3.4cm in size) appearing to arise from the region of the left atrioventricular junction. Ao, aorta; LA, left atrium, L, left ventricle.

2.Harpaz D, Auerbach I, et al. Caseous calcification of the mitral annulus: a neglected unrecognized diagnosis. J Am Soc Echocardiogr 2001;14(8):825-831.

ACCREDITATION TIP Are you collecting cases for your logbook?

For your accreditation you may find it easier to send your cases in a powerpoint presentation.

For resources to help you to do this please visit the Accreditation pages of www.bsecho.org PA G E 16

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 17

3) Emergency sternotomy and aortic valve repair following perforation by an ablation catheter We report a case where a patient underwent emergency sternotomy and aortic valve repair following aortic root perforation by an ablation catheter.

easily into the patientâ&#x20AC;&#x2122;s oesophagus. She remained cardiovascularly stable throughout induction with a mean arterial pressure greater than 50 mmHg. Following sternotomy the pericardium was opened and 400mls of blood under pressure was evacuated which resulted in immediate improvement of her haemodynamics.

A standard 20-view transoesophageal echocardiography study was performed. A mid-oesophageal short axis view at the level of the aortic valve is shown (figure 1). The Baird sheath can be seen coming from the inferior vena cava, passing through the right atrium and entering the aortic root.

A 57-year-old female patient presented initially in 2001 with a 12 month history of palpitations and breathlessness. Twentyfour hour ECG monitoring revealed paroxysmal atrial fibrillation. She was managed conservatively with medical therapy but she remained symptomatic. In 2002 she underwent pulmonary vein isolation. This procedure was unsuccessful and her paroxysmal atrial fibrillation persisted. In 2007 a redo pulmonary vein isolation was attempted but it proved impossible to cross the inter-atrial septum and the procedure was abandoned. However, she found her symptoms increasingly disturbing and in April 2009 she was admitted electively for a redo-redo pulmonary vein isolation.

Due to the failed previous attempt the cardiologists recommended transoesophageal echocardiography (TOE) guidance for the procedure but the patient refused. During the procedure it was noted that the intra-atrial septum was tough.

The guidewire was passed successfully across the inter-atrial septum and this was confirmed by radio-opaque contrast injection. The contrast appeared in the left atrium and left ventricle following injection. At this point the guidewire was used to introduce a Baird sheath. After the insertion of the Baird sheath contrast was injected to confirm its position. The contrast appeared directly in the aortic root.

Fig. 1. Mid-oesophageal short axis view at the level of the aortic valve.

A mid-oesophageal long axis view of the aortic valve (figure 2) demonstrated mild aortic incompetence due to perforation of the non-coronary cusp of the valve.

Shortly after the insertion of the Baird sheath, the patient became haemodynamically unstable with tachycardia and hypotension (HR 132 beats per minute (bpm) and non-invasive blood pressure (NIBP) 89/45). Urgent transthoracic echocardiography was performed and it revealed a small pericardial effusion. A percutaneous pericardial drain was inserted and 100ml of fresh blood was aspirated. The patientâ&#x20AC;&#x2122;s cardiovascular parameters immediately improved (115 bpm and NIBP 110/62). A Cardiothoracic surgical opinion was sought and it was felt that the patient required surgical exploration to relieve cardiac tamponade and remove the Baird sheath with the patient on cardiopulmonary bypass. The patient was therefore transferred to theatre for emergency surgery.

Prior to induction of anaesthesia, ECG and SpO2 monitoring were established. Under local analgesia, a 14G cannula was sited in the dorsum of the left hand, a 20G arterial line was placed in the left radial artery and a four lumen central venous catheter was sited in the right internal jugular vein. Anaesthesia was induced in the operating theatre with the surgical team scrubbed and the perfusionist on standby to facilitate rapid institution of cardiopulmonary bypass in the event of refractory haemodynamic decompensation. Anaesthesia was induced with midazolam, remifentanil and rocuronium, and maintained using isoflurane 1 MAC and an effect site target controlled infusion of remifentanil. A nasopharyngeal temperature probe was placed, and a transoesophageal echocardiography probe was inserted

Fig. 2. Mid-oesophageal long axis view of the aortic valve.

After the Baird sheath was removed a fistula became visible between the aortic root and the right atrium (figure 3).

Other TOE findings were a thickened, intact intra-atrial septum, moderate mitral regurgitation, mild tricuspid regurgitation and good left ventricular function. The aortic valve was repaired with a bovine pericardial patch, the fistula was sutured closed and pulmonary vein isolation was performed. Post-operatively the patient was transferred to the intensive care unit. Her recovery was uneventful and she was discharged from hospital seven days later in sinus rhythm.

PA G E 17

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 18

is a relatively fixed and low stroke volume with elevated venous pressures and cardiac output is almost entirely rate dependent.

Affected patients are at high risk of fatal haemodynamic decompensation following induction of anaesthesia due to further myocardial depression, vasodilatation or bradycardia.

The maxim ‘fast, full and tight’ has been used to describe the haemodynamic targets which represent the optimum in these patients. Anticholinergic agents and vasoconstrictors are useful; inotropic agents are not.

Conclusion

Fig. 3. Fistula between the aortic root and right atrium Discussion Atrial fibrillation is the most common supraventricular tachyarrhythmia with an incidence of 6% in patients over the age of 65 and increasing to 10% in patients over 85 years old 1.

Initiation of atrial fibrillation is most commonly due to atrial ectopic beats from ectopic foci. These ectopic foci are frequently located in the left atrium at the origins of the pulmonary veins 2. Radiofrequency pulmonary vein isolation is used for the treatment of recurrent, drug resistant atrial fibrillation 3. A recent meta-analysis found that pulmonary vein isolation resulted in maintenance of sinus rhythm at one year of 77%, compared to 29% in patients treated with medical therapy (odds ratio, 9.74; 95% CI, 3.98 to 23.87) 4.

Pulmonary vein isolation is associated with a variety of major complications, the incidence of which ranges from 2.6 4 to 6% 5.

Major complications are defined either as those that require intervention, or result in prolonged hospitalisation or long-term disability. Complications include vascular access complications, atrial flutter of new onset (3.7%), pulmonary vein stenosis of greater than 50% (1.3%), cardiac perforation/tamponade (1.2%), thromboembolic events (0.28%) and extracardiac injury (such as atrio-oesophageal fistulas, perioesophageal vagus plexus injury and transient phrenic nerve injury) 3. A large prospective observational study investigated risk factors for the development of complications, which include female sex, repeat procedure, coronary artery disease and advanced age (greater than 70 years old) 6. The National Institute of Health and Clinical Excellence produced guidelines in March 2009 regarding percutaneous (non-thoracoscopic) epicardial catheter radiofrequency ablation for atrial fibrillation7.

The guidelines do not mention the use of transoesophageal echocardiography to assist the trans-septal placement of the ablation sheath. The risk of major complications in this case was likely to be higher as the patient possessed two risk factors (female gender and having a repeat procedure).

Transoesophageal echocardiography was recommended by the cardiologists but refused by the patient. Currently there are no guidelines as to whether this could justifiably be regarded as a contraindication to performing the procedure.

In the acute setting, cardiac tamponade can be caused by a relatively small pericardial effusion. The classic triad of cardiac tamponade is decreasing arterial pressure, increasing venous pressure and muffled heart sounds. This manifested itself as hypotension, tachycardia and a raised central venous pressure (CVP). The effusion causes impairment of biventricular filling although intrinsic ventricular function is unaffected. The result PA G E 18

Pulmonary vein isolation is an effective treatment for recurrent drug resistant atrial fibrillation but it is associated with major complications. The risk of major complications in our case was likely to be higher as the patient possessed two risk factors, (female gender and a repeat procedure). Transoesophageal echocardiography was recommended by the cardiologists for the initial procedure but was refused by the patient. Currently there are no guidelines on the use of TOE to aid trans-septal puncture during pulmonary vein isolation. Transthoracic echocardiography was used to diagnose a pericardial effusion but a detailed examination was not performed due to the patient’s cardiovascular instability. Perforation of the aortic valve and the presence of the fistula following removal of the Baird sheath were diagnosed using transoesophageal echocardiography in the operating theatre. This case demonstrates the usefulness of TOE to assist trans-septal puncture during difficult cases of pulmonary vein isolation, to aid the surgical management of complications, and the importance of on-site cardiothoracic anaesthetic and surgical expertise.

Alan A. Ashworth, Donna L. Greenhalgh and Mark R. Patrick University Hospital of South Manchester References 1.Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age, distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med 1995; 155: 469-473.

2.Gill JS. How to perform pulmonary vein isolation.

Eurospace 2004; 6: 83-91.

3.Takahashi A, Kuwahara T, Takahashi Y. Complications in the catheter ablation of atrial fibrillation – incidence and management. Circulation 2009; 73: 221-226.

4.Piccini JP, Lopes RD, Kong MH, Hasselblad V, Jackson K, Al-Khatib SM. Pulmonary vein isolation for the maintenance of sinus rhythm in patients with atrial fibrillation: a metaanalysis of randomized, controlled trials. Circulation 2009; 2: 626-633.

5.Cappato R, Calkins H, Chen SA, et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation 2005; 111: 1100-1105.

6.Spragg DD, Dalal D, Cheema A, et al. Complications of catheter ablation for atrial fibrillation: incidence and predictors. J Cardiovasc Electrophysiol 2008; 19: 627-631.

7.Percutaneous (non-thoracoscopic) epicardial catheter radiofrequency ablation for atrial fibrillation. National Institute for Health and Clinical Excellence (NICE) guidelines 2009; 294. http://www.nice.org.uk/Guidance

HOT2 – 10 stations including test coffee

13.30 – 14.00 14.00 – 16.10 16.10 – 16.20 16.20 – 16.40 16.40 – 16.55 16.55 – 17.15 17.15 – 17.30

Assessment of the right heart Bushra Rana

Lunch

The mitral valve Richard Steeds

The aortic valve Kevin Fox

Break

Endocarditis & cardiac masses Antoinette Kenny

Rudiments of adult congenital Gill Wharton

12.00 - 13.00

13.00 - 13.45

13.45 - 14.30

14.30 - 15.15

15.15 - 15.45

15.45 - 16.15

16.15 - 16.45

Please note that sessions and timings are provisional and subject to change

certificates and close

local implementation and organisation

pitfalls

pericardiocentesis – echo guided

FEEL – the algorithm

lunch

12.30 – 13.25

11.15 - 12.00

Assessment of the left ventricle (systole & Diastole)

Break

11.00 - 11.15

HOT1 – 10 stations

coffee

10.00 – 10.25

How to report an echocardiogram Nav Masani

10.30 - 11.00

10.30 – 12.40

ventricular function and sono pathology

09.05 – 09.45

The complets echocardiogram - a protocol Gill Wharton

10.00 - 10.30

sono anatomy

08.45 – 09.05

welcome & introduction

coffee and registration

The physics of ultrasound & instrumentation Richard Wheeler

08.30 – 08.45

08.00 – 08.30

©FEEL – UK™: Course Programme

09.00 - 10.00

Core Training Day

BSE Core Training Day, FEEL-UK Training Day and Accreditation Examinations

Thursday 28th

Address: Bournemouth International Centre, Westover Road, Bournemouth BH1 2BU

16:58

GETTING TO BOURNEMOUTH

Bournemouth International Airport is 10 minutes from the town centre via the A338 (Wessex Way). Thomson Fly, Ryanair and Easyjet fly to and from numerous European locations, visit their websites for further information.

Bournemouth is served by 2 trains an hour from London Waterloo, the journey time is around 2 hours visit the South West Trains website for timetable information.

Main line links to the North and Scotland arrive at Bournemouth Railway Station visit the Virgin Trains website for timetable information. Bournemouth Station is a 10 minute taxi ride from the Bournemouth International C

Travelling by Air & Rail

Continue along Exeter Road to the next roundabout. Take the first exit into Westover Road. The Pavilion car park (pay & display) is on the left.

From the North and West: Head for the A31 / A338 junction (Ashley Heath) just outside Ringwood, taking the A338 (Wessex Way) to Bournemouth. Then follow the directions from the Bournemouth West Roundabout.

13/9/10

treasure) which is conveniently placed between the BIC and the Royal Bath hotel.

The restaurant/bar is located on Bournemouth Beach…therefore our theme for 2010 is “Echo Beach”

SOCIAL EVENT The annual social event will take place at Aruba (Bournemouth’s hidden

The majority are within a 10 minute walk of the BIC and single occupancy rooms begin at £60 per person per night.

Delegates can book accommodation online, via the link in the Annual Meeting section of www.bsecho.org

Registration & The Venue Refer to details below & oposite.

Driving From London: Take the M25, then the M3, M27 and A31 to Ringwood. From Ringwood, follow the A338 (Wessex Way), to the Bournemouth West Roundabout.

Accommodation Accommodation has been sourced at a variety of Bournemouth hotels. From The Bournemouth West Roundabout: Take the first exit and follow the brown signs to the BIC.

BSE ANNUAL CLINICAL & SCIENTIFIC MEETINGS BOURNEMOUTH 28th - 30th OCTOBER 2010

BSE_ECHO_No71 BS Single Page 19

PA G E 19

PA G E 20

SIMPLE: The Tricuspid Valve: • Cause of TR Alison Heads-Baister • Assessing Severity of TR Bushra Rana • Indications for Surgery of the TV Rajamiyer Venkateswaran Chair: Nicola Smith AGM

13:00 - 14:30 Session 3

16:30 - 17:30

15:30 - 16:30 Session 4

12:00 - 13:00

10:00 - 10:30

Hospital Challenge Quiz Masters: Richard Jones / Gill Wharton

Tea and Exhibition

Lunch & Exhibition

Coffee and Exhibition

Registration

• Optimising images in echo: is a hand-held enough?

Dr Richard Bogle • What is an innocent murmur on echo: Madalina Garbi • Appropriateness issues in echo: TBC Chair: M. Mahendran

COMPLEX: Tetralogy of Fallot • Anatomy of Tetralogy Of Fallot Karen McCarthy • Surgical options: past and present Mr David Barron • Echo follow-up in the adult George Ballard Chair: Richard Wheeler

COMPLEX: Echo in the 30 yr old with • ccTGA Gill Wharton • Fontan George Ballard • Pulmonary hypertension Gerry Coghlan Chair: Guy Lloyd

Accreditation: • Department Accreditation Helen Rimington • FEEL Accreditation Susanna Price • Quality Assurance Keith Pearce Chair: Ranjit More, Blackpool

16:58

15:00 - 15:30 UK BSE Invited Lecture: What operations are done in congenital heart disease?

Paul Clift Chair: Helen Rimington (VP)

SIMPLE: How to Assess: • Anatomy of the septum Karen McCarthy • Atrial Septal Defects Laurence O’Toole • Ventricular Septal Defects Navroz Masani Chair: Julie Sandoval, Sheffield

10:30 - 12:00 Session 2

08:30 - 09:00

13/9/10

14:30 - 15:00

Diagnostic challenges • ? Cardiac source of embolism Hollie Brewerton • ? Endocarditis Lorraine Lee • ? Cardiac Tamponade Jane Allen Chair: Alison Heads-Baister

09:00 - 10:00 SIMPLE Session 1

Friday 29th

BSE_ECHO_No71 BS Single Page 20

15:30 - 16:30

14:30 - 15:30 Session 4

SIMPLE: Sonographer-led services.

• The Echo Consultant Role Fay Ahmad • Contrast Waheed Akhtar • Valve Clinic Helen Rimington Chair: Jude Skipper Gems from the Presidents • John Chambers • Mark Monaghan • Gordon Williams • Navroz Masani 16:30 - 17:00

COMPLEX: BSE/ACTA TOE • TOE in transplantation Andy Roscoe • TOE in Ischaemic MR Donna Greenhalgh • TOE in Secondary TR Nicholas Fletcher Chair: Henry Skinner COMPLEX: Stress Echo • Aortic stenosis John Chambers • Viability Mark Monaghan • Mitral disease Jane Hancock

Chairs: Fay Ahmad, Rachael James, Keith Pearce

• BSE Scientific Investigator of the Year

Technical Abstracts • BSE Investigator of the Year

COMPLEX: BSE TOE • TOE Minimum Dataset Richard Wheeler • TOE Artefacts Antoinette Kenny • TOE in ACHD Nav Masani Chair: Richard Jones

Leaving Coffee and Cakes

Lunch & Exhibition

Coffee and Exhibition

Registration

16:58

13:30 - 14:30 Session 3

SIMPLE: The LA: dangerous to ignore • Assessing LA size Adrian Chenzbraun • The LA in context: prognosis Gordon Williams • The LA as a Barometer: Diastolic Function Thomas Matthew Chair: Dave Oxborough 10:30 - 11:00 SIMPLE: Assessing prosthetic values • Normal mitral prosthetic values Rick Steeds • Abnormal mitral prostheses Guy Lloyd • Normal aortic prosthetic values Rick Steeds • Abnormal aortic prostheses John Chambers Chair: Jane Lynch 12:30 - 13:30 International Lecture: Contrast Invited Speaker: Robert Amyot Chair: President Navroz Masani

09:00 - 09:30

13/9/10

11:00 - 12:30 Session 2

09:30 - 10:30 Session 1

Saturday 30th

BSE_ECHO_No71 BS Single Page 21

PA G E 21

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 22

4) Multiple cardiac papillary fibroelastomas in association with rheumatic heart disease A 49yr old woman presented with breathlessness and leg oedema. The shortness of breath had been slowly progressive over the previous three years. Past medical history was largely unremarkable and in particular there was no history of rheumatic fever. She had presented with breathlessness and haemoptysis during a pregnancy eleven years earlier but investigations revealed no evidence of pulmonary embolism.

Fig. 1. CPF attached to the lateral wall of the LV - TTE zoomed A4Ch view.

Clinical examination revealed decompensated biventricular failure and rapid atrial fibrillation. She had finger clubbing but had been known to have â&#x20AC;&#x153;roundedâ&#x20AC;? finger nails even in her 20s.

Cardiac auscultation revealed a murmur of mitral regurgitation at the apex. She had tender hepatomegaly.

A subsequent bedside TTE showed severe, rheuamtic mixed mitral valve disease with mild tricuspid regurgitation and moderate pulmonary hypertension. On further review, the TTE also showed an unusual appearance of the aortic valve with a small mobile mass attached to the ventricular side of the non-

Fig. 2. 2CPFs attached to the aortic valve - zoomed TOE SAX view.

PA G E 22

Fig. 3. 2CPFs attached to the aortic valve -TOE LAX view. coronary cusp (NCC) and a further spherical mass was seen just above the left coronary cusp (LCC). There were ill defined mobile shadows on the mitral valve and a further spherical mass attached to the lateral wall of the LV near the apex. (Figure 1).

A transoesophageal echocardiogram confirmed severe rheumatic mitral valve disease with multiple masses on the ventricular side of the mitral valve and two spherical masses on the NCC and LCC of the aortic valve.(Figures 2-3) A further mass was evident in the LV near the apex.

In view of her progressive breathlessness, finger clubbing and pulmonary hypertension, a respiratory opinion was sought and a CT scan of her thorax organised. This revealed mediastinal lymphadenopathy of up to 4cm. A diagnosis of possible lymphoma was raised but later refuted after a negative transoesophageal mediastinal lymph node biopsy showing reactive lymphadenopathy.

Cardiac surgery was performed successfully with mechanical aortic and mitral valve replacements. At surgery she was found to have multiple gelatinous masses which were all excised.

Subsequent histology revealed these masses to be typical papillary fibroelastomas (CPF). (Figures 4-5).

The post operative course was uneventful and her exercise tolerance has improved to levels which she had not experienced for five years or more.

Discussion: CPFs are usually found to be small pedunculated masses on short stalks. They commonly measure around 1cm but can be as large as 4cm.2 On gross inspection they are likened to a sea anemone due to numerous and delicate fronds. (Figure 5) CPFs have a predilection for heart valves where 80% are found 3 (35% aortic valve, 25% mitral valve, 17% tricuspid and 13% pulmonary) although they can be found anywhere attached to the endocardium.4 On atrioventricular valves they are most often found on the atrial surface and on semi lunar valves they can be found on either side.5 There is no male or female predominance and the tumours have been found in patients as young as a 6 day old neonate and in a 92yr old although they are most commonly found after the 5th decade.1 Although up to 50% of patients with CPFs are asymptomatic and the tumours are histologically benign, they are associated with serious clinical consequences due to embolisation. It is thought that rather than tumour material embolising, the tumour surface acts as a nidus for platelet and fibrin deposition which then has the potential to embolise.6 If the tumours are left sided, neurological complications including stroke are frequent.7 Other embolic complications include myocardial infarction8,9 , retinal artery embolism10, pulmonary embolism11 and sudden death.12

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 23

Conclusion: Cardiac papillary fibroelastomas are rare primary tumours of the heart. Although histologically benign, they can cause serious embolic complications. They are most commonly found incidentally by TTE or TOE. Surgical excision even in asymptomatic individuals is advised due to their potential for embolic complications.

L Bhalla, R Wheeler, Mr. Peter O’Keefe University Hospital of Wales References: 1.Shahian DM, Labib SB, Chang G. Cardiac papillary fibroelastoma. Ann Thorac Surg 1995;59:538-41.

2.Abu Nassar SG, Parker JC Jr. Incidental papillary endocardial tumour. Its potential significance. Arch Pathol 1971;92:370–6 3.Ryan PE Jr, Obeid AL, Parker FB Jr. Primary cardiac valve tumors. J Heart Valve Dis 1995;4:222-6.

Fig. 4. Excised aortic valve with attached CPFs. Due to their embolic potential, the consensus is that even asymptomatic individuals should be considered for surgery and most clinicians advocate anticoagulation. Surgical excision is curative and no case of CPF recurrance has been reported.

The case described above is unusual in having multiple papillary fibroelastomas on 3 different sites within the heart and the very rare association of rheumatic disease and CPFs which to our knowledge has only been reported once before.13 This case also demonstrates the usefullness of both transthoracic and transoesophageal echocardiography in assessing intracardiac tumours. With modern ultrasound machines the precise location and size of intracardiac masses can be defined along with their site of attachment and their relationship to surrounding structures.

TTE is an accurate modality for detecting intracardiac tumours with a reported sensitivity of 88.9% and a specificity of 87.8% for tumours > 0.2cm. However for tumours < 0.2cm the sensitivity of TTE is lower at 61.9% compared to 76.6% for TOE.14 TOE also supersedes TTE in being able to guide therapy. Peri-operative TOE has been utilised to confirm complete excision of the tumour and to test the effectiveness of the accompanying valve repair.15

4.Grinda JM, Couetil JP, Chauvand S, D’Attelis N, Berrebi A, Fabiani JN, et al. Cardiac valve papillary fibroelastoma: surgical excision for revealed or potential embolization.

Journal of Thoracic and Cardiovascular Surgery 1999;117:106-10.

5.Edward FH, Hale D, Cohen A, et. al. Primary cardiac valve tumors. Ann Thorac Surg. 1991;52:1127–1131.

6.Mc Fadden PM, Lacy JR. Intracardiac papillary fibroelastoma: an occult cause of embolic neurologic deficit.

Ann Thorac Surg 1987;43:667-9.

7.Matsumoto N, Sato Y, kusama J, Matsuo S, Kinukawa N, Kunimasa T, Ichiyama I, Takahashi H, Kimura S, Orime Y, Saito S. Multiple papillary fibroelastomas of the aortic valve: case report. Int J Cardiol 2007;122:e1–3.

8.Israel DH, Sherman W, Ambrose JA, et al. Dynamic coronary ostial obstruction due to papillary fibroelastoma leading to myocardial ischaemia and infarction. Am J Cardiol 1991;67:104–5.

9.Etienne Y, Jobic Y, Houel JF, et al. Papillary fibroelastoma of the aortic valve with myocardial infarction: echocardiographic diagnosis and surgical excision. Am Heart J 1994; 127:443–5.

10.Zamora RL, Adelberg DA, Berger AS, et al. Branch retinal artery occlusion caused by a mitral valve papillary fibroelastoma. Am J Ophthalmol 1995;119:325–9.

11.Waltenberger J, Thelin S. Images in cardiovascular medicine. Papillary fibroelastoma as an unusual source of repeated pulmonary embolism. Circulation 1994;89:2433.

12.Amr SS, Abu Al Ragheb SY. Sudden unexpected death due to papillary fibroma of the aortic valve. Report of a case and review of the literature. Am J Forens Med Pathol 1991;12:143–8.

13.Kalman JM, Lubicz S, Brennan JB, et al. Multiple cardiac papillary fibroelastomas and rheumatic heart disease. Aust NZ J Med 1991;21:744–6.

14.Sun JP, Asher CR, Yang XS, Cheng GG, Scalia GM, Massed AG, et al. Clinical and echocardiographic characteristics of papillary fibroelastomas: a retrospective and prospective study in 162 patients. Circulation 2001;103:2687-93.

Fig. 5. CPF in saline showing the characteristic “sea anemone” appearance.

15.Minatoya K, Okabayashi H, yokota T, et al. Cardiac papillary fibroelastoma; rational for excision. Ann Thorac Surg 1996;62:1519–21.

PA G E 23

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 24

5) Caution Required the IVC to be clear. This image highlights the fact that a definitive diagnosis should not be attempted from echocardiographic images alone.

The above image shows a large mass present in the inferior vena cava (IVC). Without considering the clinical data alongside, the echocardiographic finding suggests a finger like mass which may be mistaken for a renal carcinoma infiltrating into IVC. One week on following a course of heparin, repeat echo shows

1 week on Paul Russhard, Deepa Sureshkumar, Basildon Hospital, Essex

6) “Fluid around the heart” – is it always pericardial or pleural?

A 72 year old man had a transthoracic echocardiogram performed as part of an investigation into a recent episode of chest pain. He was known to have severe liver disease although this was not recorded on his in patient request form.

Parasternal and apical views were relatively unremarkable but the subcostal view surprisingly showed a large echo free area adjacent to the anterior border of the right ventricle. In addition there was a thin strand of “tissue” running across this presumed collection of fluid and it appeared to oscillate (Figures 1 and 2).

Fig. 2. An off axis subcostal view demonstrating the falciform ligament (white arrow).

Analysis of the previous parasternal and apical views revealed no pericardial or pleural effusions and transmitral pulsed wave doppler showed no respiratory variation. The sonographer requested a medical opinion within the cardiac department and the patient’s hospital notes were reviewed. This confirmed the patient had severe liver disease and had significant ascites clinically and on a recent abdominal ultrasound. In addition a chest x-ray performed on the same day was carefully inspected and confirmed the absence of any pleural effusions.

Fig. 1. Subcostal view with a large collection of fluid adjacent to the anterior border of right ventricle (white arrow) and a linear strand of “tissue” within it (green arrow).

PA G E 24

We concluded that this collection of fluid was intra-abdominal fluid and in the clinical context was due to ascites secondary to his known advanced cirrhosis of the liver.

BSE_ECHO_No71 BS Single

13/9/10

16:58

Page 25

Discussion There is little published on the transthoracic echocardiographic images of ascites and consequently the finding of an echofree area around the heart that does not fit with either pericardial or pleural fluid may cause confusion for the sonographer.

We reviewed the literature and found a publication that specifically investigated TTE on patients with ascites and described the echocardiographic features that would aid a sonographer in confirming the fluid they saw was ascites 1.

In this study they purposefully performed transthoracic echocardiography on 32 patients with ascites. On the subcostal view in each case they found that a strand of tissue (the falciform ligament) that bisected the translucent space between the right border of the heart and the liver was always present.

They concluded that the presence of the falciform ligament in this echolucent space confirms ascites.

The falciform ligament is a fold of peritoneum that is firmly attached to the liver and reflects back on to the posterior abdominal wall and then on to the inferior surface of the diaphragm (Figure 3).

It only becomes apparent on TTE when there is a significant amount of fluid on either side of this structure as occurs in ascites or with a large intra-peritoneal bleed. The authors of this study also noted that the falciform ligament made characteristic wave-like motions within the space and presumed that this was due to indirect transmission of the cardiac motion to the ligament.

The translucent space seen on TTE is fluid below the diaphragm and therefore the fluid is not in direct contact with the heart and therefore does not cause cardiac tamponade.

This case report confirms this very useful echocardiographic finding but we would advise sonographers to confirm that ascites is present in these patients before concluding that an echolucent space around the heart is in fact due to ascites. This may be confirmed by simply reviewing the notes or looking up other radiological tests such as abdominal ultrasound or CT. References 1.Cardello FP, Dong-Hi AY et al. The falciform ligament in the echocardiographic diagnosis of ascites. Journal of the American Society of Echocardiography 2006; 19(8):1074.e31074.e4 Acknowledgements: We would like to acknowledge that the post mortem image was kindly provided by Dr Mark Deverell, Pathologist, Poole Hospital GLA Cumberbatch, Jodie Taplin, Poole Hospital

Fig. 3. The falciform ligament is nicely demonstrated (white arrow) as is the potential space where the ascites collects between the liver (black arrow) and diaphragm

BSE COUNCIL NOMINATIONS The BSE Council comprises 10 elected members (who are automatically Trustees of the Charity and Directors of the Company). They serve a 3-year term and can, if they wish, seek election for a second term.

The President is chosen from Council members and remains a member for the duration of office plus an additional year as ‘Immediate Past-President’. The elected members can co-opt additional members who each serve for a one-year term. This year there are three vacancies for elected Council members to serve from 20102013. These will be filled by on-line ballot which will be available from 11th – 22nd October.

We want the Council to reflect all members of the Society so all members are encouraged to stand for election and to vote once the elections open.

Anyone wishing to nominate a candidate should to so in writing via email to: secretary@bsecho.org. Email is the preferred option for receipt of nominations however postal nominations can be sent to the BSE Hon. Secretary, Docklands Business Centre, 10–16 Tiller Road, London, E14 8PX. Nominations must be received by Friday 8th October and be accompanied by a declaration from the candidate that s/he is willing to stand for election, plus a statement of a maximum of 150 words in support of his/her application.

Any BSE member can serve on the Council. It is very important that the Council reflects the membership as a whole, both professionally and geographically. If you would like to learn more about what is involved before deciding whether to stand for election please contact the President at Council@bsecho.org or the Hon Secretary at Secretary@bsecho.org PA G E 25

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 26

3D SPECKLE TRACKING – A NEW ERA FOR ECHOCARDIOGRAPHY AND MYOCARDIAL IMAGING?

What is Speckle Tracking?

Tissue Doppler imaging (TDI) was the first technique used to assess regional wall deformation, strain and strain rate.

However, this method suffered mainly from being angledependent (due to the use of Doppler) 1. Two-dimensional speckle-tracking echocardiography (2D-STE) was introduced in order to solve this issue. 2D-STE analyzes wall motion by following acoustic markers on gray-scale images and integrating frame-to-frame changes but is limited by its twodimensional (2D) nature 2. Speckles are tracked in 2D planes and therefore only a portion of motion is detected since speckles move in three dimensions.

Concept of 3D Speckle Tracking Recently, the concept of speckle tracking in three dimensions has been applied, permitting assessment of real movement and true three-dimensional (3D) strain analysis. 3D-STE uses the pattern-matching technology in real 3D motion vectors within the acquired 3D volume. The use of 3D-STE for left ventricular (LV) volume quantification and for regional strain measurement has been validated against cardiac magnetic resonance (CMR) and sonomicrometry 3,4,5. Other studies evaluated 3D-STE in comparison to 2D-STE and reported that 3D-STE is less timeconsuming, enabling the analysis of a greater number of segments 6, 7. Tanaka et al reported that 3D-STE could successfully quantify 3-D dyssynchrony and the site of latest mechanical activation 8. Currently, the use of 3D-STE is expanding taking advantage of its unique ability to assess and quantify reliably and in three dimensions any deformation abnormality before it becomes visually recognisable (asymptomatic patients with normal systolic function and ischemia or severe valvular disease) and to guide clinical decisions on further treatment (early identification of chemotherapy-induced cardiomyopathy).

Practicalities of 3D Speckle Tracking Standard acquisition is rapid as only a single apical full volume data set acquired from four consecutive cardiac cycles during breath hold is required for subsequent off line analysis.

Endocardial and epicardial contours are traced and the dedicated software (Toshiba Artida, Toshiba, Tokyo, Japan) tracks the contours in subsequent frames to calculate strain parameters (radial, longitudinal and circumferential strain, apical and basal rotation and torsion) in all sixteen LV wall segments within a few seconds. Frame by frame wall motion parameters are colour coded and can also be displayed as a dyssynchrony imaging map.

Research applications of 3D Speckle Tracking 3D-STE is currently being applied in a range of research studies within the Oxford Cardiovascular Clinical Research Facility because of its ability to provide rapid 3D assessment of myocardial strain. Changes in myocardial function may be of key importance in the early development of the cardiovascular dysfunction that precedes many clinical conditions. 3D STE therefore offers an opportunity to identify factors that influence disease development, monitor progression and assess response to preventative treatment. There are particular focuses on the myocardial dysfunction associated with valve disease, hypertension and ischaemia with several large scale studies and clinical trials in progress.

Conclusion 3D-STE has emerged as a rapid and simple tool to collect information on myocardial function in both the clinical and research setting. Ongoing work has the potential to identify new clinical applications of 3D-STE as well as use 3D-STE as a means to understand biological changes in myocardial function PA G E 26

from early in the development of a range of cardiovascular diseases.

Christos Basagiannis, Paul Leeson John Radcliffe Hospital, Oxford References 1.Marwick TH. Measurement of strain and strain rate by echocardiography: Ready for prime time? J Am Coll Cardiol 2006, Apr 4; 47(7): 1313-27.

2.Pérez de Isla L, Vivas D, Zamorano J. Three-Dimensional speckle tracking. Current Cardiovascular Imaging Reports 2008; 1(1): 25-9.

3.Maffessanti F, Nesser HJ, Weinert L, Steringer-Mascherbauer R, Niel J, Gorissen W, et al. Quantitative evaluation of regional left ventricular function using three-dimensional speckle tracking echocardiography in patients with and without heart disease. Am J Cardiol 2009, Dec 15;104(12):1755-62.

4.Seo Y, Ishizu T, Enomoto Y, Sugimori H, Yamamoto M, Machino T, et al. Validation of 3-dimensional speckle tracking imaging to quantify regional myocardial deformation. Circ Cardiovasc Imaging 2009, Nov;2(6):451-9.

5.Nesser HJ, Mor-Avi V, Gorissen W, Weinert L, SteringerMascherbauer R, Niel J, et al. Quantification of left ventricular volumes using three-dimensional echocardiographic speckle tracking: Comparison with MRI. Eur Heart J 2009, Jul; 30(13):1565-73.

6.Pérez de Isla L, Balcones DV, Fernández-Golfín C, MarcosAlberca P, Almería C, Rodrigo JL, et al. Three-DimensionalWall motion tracking: A new and faster tool for myocardial strain assessment: Comparison with two-dimensional-wall motion tracking. J Am Soc Echocardiogr 2009, Apr; 22(4): 325-30.

7.Saito K, Okura H, Watanabe N, Hayashida A, Obase K, Imai K, et al. Comprehensive evaluation of left ventricular strain using speckle tracking echocardiography in normal adults: Comparison of three-dimensional and two-dimensional approaches. J Am Soc Echocardiogr 2009, Sep; 22(9): 102530 8.Tanaka H, Hara H, Saba S, Gorcsan J 3rd. Usefulness of three-dimensional speckle tracking strain to quantify dyssynchrony and the site of latest mechanical activation.

Am J Cardiol, 2010 Jan 15; 105(2): 235-42.

Installation of Toshiba Artida in the Oxford Cardiovascular Clinical Research Facility (CCRF), located within the John Radcliffe Hospital. CCRF provides a dedicated, staffed clinical research environment, with particular expertise in echocardiography, vascular assessment and clinical physiology.

(Left to right) Dr. Merzaka Lazdan, Dr. Paul Leeson, Mair Howe and Helen Deacon Toshiba Medical Systems, Ms Arancha della Horra and Dr. Saul Myerson.

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 27

Win a £75 book voucher by being the first to submit a correctly completed answer

ECHO CRYPTIC CROSSWORD

Across 2. It's the limit when a sport's brand sponsors a card game! (7) 6. Constricting female hygiene device helps we hear (9) 7. We hear Tony from 'Vision-On' painted an organ (5) 8. Plant foliage rented by flier (7) 9. Charles' double, no gang but still shifty (7) 10. Initially frog’s legs are incredibly light so can thresh about! (5) 13. Even a good rule, if not perfect, is still a helpful haemodynamic formula (6) 16. Reportedly tide flows back from river in Newcastle is anomalous defect (7) 17. Four deer were seen on unseeded land we hear (9) 18. Broken poem before actress Ms Thompson swells up! (6) 19. Wild rodent approaches city with direction and speed (8)

Down 1. In front and into rear (8) 3. Syndrome sheep returns before groupies (7) 4. To start, all oxygen rides through a tube (5) 5. Did muddled Clive rent chamber? (9) 8. I own this muddy path- no I do, rising as high as a clerical hat! (6) 11. Muddled nest is so narrowed (8) 12. Little ring invalidated us (7) 14. Firstly, Richard has yoga to help movement through time (6) 15. Ultrasound technique broadcasts rap star’s poem (5)

This crossword devised by Stuart Self, Chief Cardiac Physiologist, York Hospital.

Submit a copy of your completed crossword, with your name and address to the BSE Office.

The first correct answer opened, wins.

PA G E 27

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 28

Reply from the Education Committee

LETTERS TO THE EDITOR

Dear Dr Shah 1) Response to BSE Guidelines: Mitral Valve Repair (published June 2010) Dear Education Committee I read the recently published BSE guidelines on 2-dimensional transthoracic assessment of the mitral valve with great interest and thank the education committee for this comprehensive and very helpful publication. I wish to raise two points for consideration.

Firstly, the section on leaflet motion (in the PLAX view) describes Carpentier type 3a as leaflet restriction in systole alone and type 3b as restriction in both systole and diastole.

However, the original Carpentier classification system described type 3a as restriction in systole & diastole (e.g. rheumatic mitral disease) and type 3b as restriction in systole alone (e.g. chronic ischaemic MR). The 2006 American (ACC/AHA) guidelines on management of valvular heart disease similarly describe restriction in systole and diastole (type 3a) or systole alone (type 3b), respectively.

Secondly, the apical 2 chamber view (AP2C) is described as showing the scallops A1/A2/(A3) and P3. However, again, this appears to be in contrast to several other texts. The AP2C view - sometimes called the inter-commissural view â&#x20AC;&#x201C; is usually said to demonstrate the P1 scallop on the left (adjacent to the aorta), the P3 scallop on the right (adjacent to the atrial appendage) with the A2 scallop in between. The Oxford specialist handbook of echocardiography, ESC textbook of cardiovascular medicine and the education section of the European association of echocardiography (EAE) website all also state that P1-A2-P3 are, generally speaking, the scallops seen in the A2PC view.

The latter two aforementioned sources cite a JACC paper by Monin et al in 2005 as their reference (also used in the BSE guidelines).

The Education Committee are grateful for your kind comments and feedback in relation to the recently published Guideline Protocol for the Assessment of the Mitral Valve with a View to Repair. You raised two points.

Firstly, thank you for pointing out the printing error in relation to the section on leaflet motion. The Carpentier classification type 3a does refer to a restriction in systole & diastole (e.g. rheumatic mitral disease) and type 3b as restriction in systole alone (e.g. chronic ischaemic MR) - and not the other way round (as originally printed). This has been corrected in the version available on the website.

Secondly, the paper by Monin used as a reference does describe the transthoracic apical two chamber view as demonstrating an inter-commissural image of the mitral valve, with the P1 scallop on the left (adjacent to the aorta), the P3 scallop on the right (adjacent to the atrial appendage) and the A2 scallop in between. This has been slavishly copied without discussion into The Oxford Specialist Handbook of Echocardiography, The ESC Textbook of Cardiovascular Medicine and the education section of the European Association of Echocardiography (EAE) website.

The Education Committee take the practical view that the scallops which can be seen from this acoustic window depend on the orientation of the heart and the degree of rotation of the probe. With minor changes in orientation of the heart and rotation of the mitral valve, two images can be produced â&#x20AC;&#x201C; either the P3-A123, as shown in our document, or P3/A2/P1 shown below. There is very little movement required between these two, and we have added this into our dataset to explain this more fully.

I would thus be most grateful if the Education committee could clarify these two issues.

Yours sincerely Dr Benoy N Shah Cardiology SpR, Southampton University Hospital

References Steeds R, Rana B et al. A guideline protocol for the assessment of the mitral valve with a view to repair from the British Society of Echocardiography Education Committee. ECHO; June 2010; 70; 9-13 Carpentier A. Cardiac valve surgery: the French connection.

J Thorac Cardiovasc Surg (1983); 86; 323 Bonow RO, Carabello BA et al. ACC/AHA guidelines for the management of patients with valvular heart disease. Circulation (2006); 114, e84-e231 Monin J-L, Dehant P et al. Functional Assessment of Mitral Regurgitation by Transthoracic Echocardiography Using Standardized Imaging Planes. J Am Coll Cardiol (2005); 46; 302-09 PA G E 28

Bushra Rana and Rick Steeds

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 29

Replies to the article on the NICE guidelines on chest pain published in the last edition of ECHO, Vol. 70 June 2010.

I would advice readers to read the above article before evaluating the following 2 replies. Editor 2) Are the NICE Guidelines really nasty?!

My, what hostility the new NICE guidance for the diagnosis of angina has caused; I have yet to find anybody ready to speak up for them. Undoubtedly this is one of the rawest, least polished documents that NICE has produces. It feels somehow unfinished, and as if a couple of further rewrites might have been of benefit. The recommendations on acute chest pain have some eccentricities but revolve around the appropriate use of ECG and biomarkers. I will not address this section but rather examine the sentiment that lies behind non acute section of the document. The guidelines are aimed quite specifically at the diagnosis of angina - not at the prognostication in people with coronary heart disease, not at directing management in coronary heart disease: simply, has this person with the symptom of chest pain got blocked arteries or not.

They acknowledge something we all know, that exercise testing, as a mass market triage tool in the Rapid Access Chest Pain Clinic is a bit rubbish. There is no doubt the exercise test is tremendously useful in selected cases, but this strategy has to run across the country in clinics, often nurse led, that are packed with people who canâ&#x20AC;&#x2122;t exercise, or have bundle branch blocks, or are women, or have LVH, or are non- caucasian, or have single vessel disease, or are at low risk, or are at high risk, or are sweaty, or are unusually hairy.

The NICE guidance offers several advantages. Firstly it reintroduces clinical judgment. If the chest pain sufferer has effectively no risk of coronary disease, do not do a test. For too long rapid access clinics have tested first and only then talked.

The performance of all non invasive ischaemia detecting tests is poor when risk is low. In this population a positive exercise test or even stress echo is quite likely to be a false positive test.

Anatomical tests, in the form of cardiac CT have something to offer both by ruling out anatomical issues, but also in flagging up the presence of atherosclerosis through a raised coronary calcium. There are however two problems with the CT recommendation; the presence of non-calcified vulnerable soft plaque in young people causes everyone anxiety although the frequency in patients presenting with chest pain is likely to be low; the other is roll out. But surely there is nothing wrong with letting a guideline express a legitimate ambition that incentives hospitals to achieve it.

If there is an intermediate likelihood that this might be genuine angina then do a test that is non invasive but also performs far and away better than an exercise test, that is a stress echo (or on a bad day a perfusion scan). The door is even left open to the exercise ECG as an indisputable useful tool in those with established coronary artery disease. If on the other hand the patient is heading for the cath lab from the first moment they open their mouth, then take them to the cath lab!

Where do these guidelines leave the echo lab? Firstly they do not undermine the pivotal role of echo in defining cardiac prognosis and management strategy through the assessment of global function and wall motion abnormalities. It is a hearts and minds initiative that is required to get the LV cineangiogram banished, with the magic lantern, to the dustbin of diagnostic history. Everyone going to the cath lab should have an echo, but this does not necessarily influence the diagnosis or angina.

Stress echo is such a valuable recourse and performs with a high level of sensitivity and specificity. This deteriorates as the chance of disease goes down and as the prevalence of single or no vessel disease goes up. Applied in the wrong population then stress echo could lose its reputation for reliability (something that has bedevilled myocardial perfusion scanning).

Reserving stress echo for cases in which it is likely to perform at high accuracy is a sensible strategy. Likewise these guidelines do not change the huge role of stress echo in defining a management strategy in patients after the cath lab.

This is an imperfect guidance certainly, and should in no way been seen as a blueprint for the total management of coronary artery disease. On the other hand as a practical strategy to decide whether someone pitching up with chest pain has blocked arteries it works rather well. It relegate forever the exercise test which is not suited to being a mass triage tool and requires considerable expertise to properly request. It re-instates the concept that where likelihood is effectively zero no test should be performed, steering us away from the American model that it is better to test someone than to talk to them.

Most importantly it incentives hospitals to make the necessary investment in advanced cardiac imaging, both in the form of a cardiac CT and a stress echo service, something they have historically failed to do.

Guy Lloyd, East Sussex NHS Trust

ARE YOUR DETAILS UP TO DATE?

Please donâ&#x20AC;&#x2122;t forget to let us know if you are changing your home address, place of work or e-mail so that we can easily contact you if we need to. This is especially important if you are currently working towards BSE Accreditation. Changes to details can be e-mailed to admin@bsecho.org PA G E 29

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 30

3) A further response to the NICE guidelines.

I read with interest your interpretation of the recent NICE guideline on chest pain diagnosis and your concern about the impact on echo services (ECHO Issue 70, June 2010). In my experience, (admittedly only 22 years rather than your 40) a rapid diagnosis of an acute coronary syndrome (ACS) is best made with an ECG rather than an echo. However, in patients with normal ECG, but suspected ACS, echo is advocated to assess for regional wall motion abnormalities. While I support paramedic assessment of patients with chest pain by recording and interpreting ECGs, it may be cumbersome and time consuming for them to perform echocardiography before deciding whether a patients needs to be admitted to hospital! In my opinion, the acute chest pain guideline gives clinicians clear pathways to diagnose and manage patients with suspected ACS including, where indicated, the use of echo.

In patients presenting with stable chest pain, the clinical assessment alone, not just history, may be sufficient to make a diagnosis of angina without the need for further diagnostic investigation. The management of angina patients is not covered in this guideline and will be addressed by NICE when they publish the stable angina guidelines in 2011. With regard to investigation of patients with ‘atypical’ chest pains, the estimation of the likelihood of coronary artery disease (CAD) is based on sound research evidence1. This is not an arbitrary percentage chance but a unique individual figure if calculated using the model suggested by Pryor et al1. CT calcium scoring is a quick, safe and accurate method of identifying coronary plaques and is advised in patients with low to moderate likelihood of CAD. In patients with a higher (30-60%) likelihood of CAD, functional testing is recommended, including stress echocardiography if preferred. Anyone with a higher likelihood should be offered diagnostic coronary angiography. It has now been widely demonstrated that the exercise tolerance test is limited in the diagnosis of chest pain and does not add prognostic value to that obtained from clinical

assessment2. This clear and systematic approach to investigating chest pains should reduce the chance of us being ‘caught out’ by atypical presentations of CAD. I may be wrong, but I am not aware of any evidence for the use of transthoracic echocardiography in the diagnosis of chest pain.

Advances in health care are vital and rarely come cheaply. They require us to challenge traditional thinking and embrace new technologies. We should never continue doing what we always did just because it is easier or seems right, when research tells us differently. The improved management of CAD now means that patients are surviving acute events in greater numbers and living longer. In asking the question “Will your Echo Service be able to cope?” the real challenge is the management of long term chronic heart disease where, you’ll be pleased to hear, I think echo has a vital role to play.

Aidan MacDermott County Durham and Darlington PCT

References: Pryor DB, Shaw L, McCants CB, et al. (1993) Value of the History and Physical in Identifying Patients at Increased Risk for Coronary Artery Disease Annals of Internal Medicine;118: 81-90 Sekhri N, Feder GS, Junghans C, et al. (2008) Incremental prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina: cohort study British Medical Journal; 337:a2240 Cooper A, Calvert N, Skinner J, et al. (2010) Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. National Institute for Health and Clinical Excellence Guideline CG95

IMEDIX SIMULATORS We are delighted to announce that Vimedix (CAE Healthcare) will be joining us in Bournemouth to host the Satellite session on the evening of Thursday 28th October.

If you will be arriving early in Bournemouth, or staying following the Core Training, FEEL or Accreditation exams, why not join us 19:30 – 21:00?

No registration is required and the session is free to attend. A buffet and drinks will be available to all attendees.

PA G E 30

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 31

BSE ACCREDITATION UPDATES Transthoracic Accreditation

The Autumn BSE exams will be held at the Royal Bath Hotel in Bournemouth on Thursday 28th October 2010.

The exam registration forms for TTE, Critical Care and Community accreditation are now live on the BSE website. They can be found, together with the accreditation packs, on the accreditation section of the site.

A new Accreditation pack (August 2010) has been introduced for Adult TTE, and candidates sitting the October 2010 exam will be expected to use the revised version. However candidates who have previously taken the examination and are due to submit logbooks by end December 2010 will have the option to use either the new or previous version. We do ask however, that candidates clearly state which version they have used when submitting their documentation.

Critical Care Accreditation BSE are delighted to announce that the Critical Care Accreditation will pilot the first set of exams in Autumn 2010. There will be no initial charge to candidates who decide to sit this pilot exam, but candidates who pass the exam can then choose to pay the usual exam fee (ÂŁ150) and proceed to the logbook section of the accreditation. Candidates who fail the examination will not be charged, and will be able to sit the exam as normal in Spring 2011.

For further clarification or information on any BSE accreditation queries, please email BSE Accreditation Administration on: bse@execbs.com.

BSE/ACTA Transoesophageal Echocardiography Accreditation The Accreditation Committee wishes to align TOE accreditation with the transthoracic process.

Logbook reports should contain a minimum dataset and five of these will be checked against the acquired images. Therefore, candidates who sit the 2010 examination must submit five digitally stored studies with each logbook. One study should be normal and one should show an example of aortic stenosis. Image acquisition, optimization and interpretation will be assessed. It is important that all reports and digital images are completely anonomysed (removal of all patient identifier data like name, date of birth, address and hospital or NHS number).

The BSE Education Committee recently produced guidelines on performing a comprehensive TOE examination. It is recognised that it may not be possible to acquire all the recommended views in all patients. In particular, there are certain probe positions that may be poorly tolerated in awake patients.

Cases must be submitted as digital loops and stills within a Powerpoint presentation or uploaded onto www.bsecho.org when this facility becomes available. Reports should include quantitative measurements, observations, summary and conclusion. An example of the marking schedule for the digital studies will be included in the new accreditation documents and can be downloaded from www.bsecho.org/accreditation.

Henry Skinner Accreditation Committee

COMMUNICATING WITH THE SOCIETY For general enquiries concerning membership subscriptions, meetings, etc.: Dawn Appleby / Ingrid Daniel

BSE Administration

Docklands Business Centre, 10-16 Tiller Road, Docklands, London E14 8PX Tel: 020 7345 5185 Fax: 020 7345 5186 Email: admin@bsecho.org Web: www.bsecho.org For queries regarding Accreditation: BSE Accreditation Administrator Executive Business Support Limited, City Wharf, Davidson Road, Lichfield, Staffordshire WS14 9DZ Tel: 0845 094 4728 Fax: 0121 355 2420 Email: BSE@execbs.com Web: www.bsecho.org BSE President: Dr Navroz Masani c/o BSE Administrator (Docklands address)

Email: council@bsecho.org

ECHO Editor: Dr Gordon Williams c/o BSE Administrator (Docklands address) Tel: +44 (0) 113 29 25 794

Fax: +44 (0) 113 39 85 265 Email: dr.gordonjwilliams@btopenworld.com PA G E 31

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 32

COMMITTEE REPORTS Treasurers Report The role of BSE Honorary Treasurer was officially handed over at the AGM in October 2009. Graham Leech had held this role for many years and had such a level of understanding, knowledge and control of the financial aspects of the Society that taking on this role was somewhat daunting.

In preparation, for the twelve months leading up to my appointment there had been several changes made, including the changing of the accounting year so that it now runs from April 1st to 31st March each year in line with the BSE Membership year. The accounts presented at the 2009 AGM reflected a 9 month period to be compared to those being prepared, as we speak, that will contain a full 12 months. The figures tabled below are taken from reports produced from the new accountancy package, SAGE. This was introduced to replace the original accountancy database as it is a recognised commercial product with training days and support provided. This system had been running alongside the original system and went ‘live’ in April 2009. Direct comparison of income and expenditure reports is also made more difficult this year due to the different categories and sub-categories now available on the new system.

Our new Accountants, Phillips Kobbs and Co Ltd., are based locally to the BSE offices and have provided on-site support and advice as the SAGE system has been set up and adapted to provide regular detailed analysis of the Societys’ financial position.

Council has agreed, following a review of our current banking arrangements, that introducing secure Internet banking would be beneficial. This system has been running for approximately six months in an attempt to reduce banking costs and speed up payment of invoices and expenses. Further changes are in process to change bank account providers from Bank of Scotland to Natwest, following a detailed comparison of services provided to us as a charity. This change will not affect the majority of members, however, if your annual subscription fee is paid by standing order, you will need to alter that instruction. We will contact you with the new details. Members who pay by Direct debit will not be affected. Once the new bank account has been finalised, the Society will re-consider their Reserves Policy together with their Bank Manager and Accountant, following amendments to the guidelines published by The Charities Commission.

Membership subscriptions raised £158,937.00 compared to £113,144 from the previous 9 months reflecting our ever increasing membership.

The Annual meeting was held in Liverpool over three days with the exams, Core Training and FEEL being held on the Thursday followed by the usual two day scientific meeting. Our social event held on the Friday evening at Circo Bar was a great success. The full breakdown of the meeting costs will be included in the completed annual returns.

Our main additional expenses this year have been very small as the Website Upgrade Phase 1 has been completed and the additional Departmental Accreditation microsite was funded by the BHF. Two new computers and a laptop have been purchased for the office.

Overall the British Society of Echocardiography bank account shows a very healthy £520,000 as of 1st April 2010.

Tracy Ryan 2009-2010 Income & Expenditure – 1 April 2009 to 31 March 2010 Income

Expenditure

Annual Subscriptions

£158757.00

Gross Wages

£52,272.27

Accreditation Fees

£102,770.00

Rent and Rates

£15,646.06

Annual Meeting

£179,287.72

Annual meeting

£161,060.03

Training Courses

£11014.76

Training

Website/Newsletter

£16759.50

Accreditation

Other income

£358.51

Travel Printing and Stationery

Total Income Surplus PA G E 32

£468,947.49

£2087.98 £75,743.47 £1774.57 £73,586.67

Professional Fees

£1011.49

Equipment Hire and Rental

£1538.77

Bank Charges

£2927.54

Subscriptions

£1023.65

Total Expenditure

£388,672.50 £80,274.99

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 33

Education Committee Report

Communications Committee Report

This year has been a busy and productive one for the Education Committee. The year started with the largest Annual General Meeting ever held by the British Society of Echocardiography, with over 750 delegates attending the new conference centre in Liverpool at the beginning of October. Before the main meeting opened, a ‘Core’ training day was held for those starting out in echocardiography, with a second training opportunity run concurrently for those wishing to use peri-arrest echocardiography. The main meeting focussed on ‘Medicine and the Heart’ and opened with a popular ‘How to…’ session run solely by sonographers with the aim of the practising echocardiographer in mind. The lectures were supported by ‘Hands-on’ sessions run by applications specialists from the major echocardiography companies, focussing on 3D assessment of the left ventricle and mitral valve. These will be run again this year and have been popular, so book early! The Annual General Meeting is returning to Bournemouth this year, where for the first time there will be parallel sessions throughout both days, enabling participants to choose between ‘simple’ and ‘advanced’ topics. Other new developments will be automated feedback and the availability of some sessions as pod casts.

Communication is a two way street, and the street is currently being repainted. The only function of the BSE is to promote the interests of its members whether through political representation, guideline and policy devolvement or by educational materials and events. As part of creating a modern society, a process has been launched to dramatically increase the amount, extent, and quality of information and direct engagement with the membership.

The educational programme continued in March with a very successful Advanced ImagingTraining day, held at the Royal Society of Medicine. This focussed on pre-operative, perioperative and post-operative imaging in the management of patent foramen ovale and mitral regurgitation. The Advanced Imaging Training day will be run at the same venue in March next year, and brings best practice in echocardiography to a broad audience of sonographers and cardiologists.

The BSE had a prominent place at the British Cardiovascular Society this year, running three full sessions on myocardial mechanics, the failing right heart and repair of the mitral valve.

The feedback from these sessions was very positive and the BSE hope to continue to have influence through the development of a new Imaging Council run by our Past President Simon Ray. The Education Committee has been busy on the writing front as well, with a full protocol published for the performance of transoesophageal echocardiography and a new version of the minimum dataset on transthoracic echocardiography in preparation. Supplementary protocols have been published on hypertrophic cardiomyopathy, Marfans syndrome, and mitral regurgitation. The next to be published will cover pulmonary hypertension, and protocols in preparation include assessment of mitral stenosis for percutaneous commissurotomy, aortic stenosis, and diastolic function. Work is also carrying on in the development of guidelines for probe cleaning and periprocedural sedation.

December 2009 saw the publication of the BSE Supplement in the European Journal of Echocardiography on Cardiomyopathies, with a further supplement to be published the same time this year on interventions relating to patent foramen ovale and mitral regurgitation. Please let us know if there are other things that you are keen for us to develop and sign up for Bournemouth!

What does this actually mean?

A new website is currently being planned. The old site contains a wealth of useful material but is of a design that is now obsolete. The new site will have a much greater diversity in linking to an on line educational hub. Embedding the already excellent paper version (which will continue in paper) of the ECHO journal, with easy access to relevant video clips.

There will be increasing interactivity with distance learning modules and an area of debate and chat which will take over from the current forum.

The objective is to make the website the ‘must see’ on line facility for all echocardiographers in the UK. But communication is about more than just websites. The Echo journal is already a fantastic facility - although short of willing authors! And there are other aspects including site visits, problem solving, local educational meetings and engagement which must all be part of the process.

Yes that is a call for volunteers!

We recently established a new team for the Communications Committee, however with a growing remit we would welcome additional members. If anybody would like to become involved with this process, then their contribution would be hugely welcomed. Areas people might like to think about are: Techies - who are good with IT and can help improve the quality of the site Librarians - who would be happy to collate image libraries Authors who want to write - Echo needs your contribution Others with good ideas that haven’t been foreseen Don’t forget to follow BSE on twitter with (increasingly) frequent updates or join the race to become BSE’s first Facebook friend.

Volunteers please.

Guy Lloyd

For up to date information on BSE and echo related stories, register to following “BSEcho” on twitter!

PA G E 33

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 34

2009 AGM MINUTES

Unconfirmed minutes of the Annual General Meeting of the British Society of Echocardiography Limited Held on Friday 2nd October 2009, 14.30 BT Conference Centre, Liverpool Present: 95 members attended the meeting 1. Apologies:

None

2. Minutes of the 2008 AGM There were no corrections to the minutes.

Proposed: Dr Kevin Fox Seconded: Gill Wharton Passed nem con 3. Matters arising There were no matters arising 4. Notification of deaths None known at the time of meeting 5. Secretaries report – Jane Allen The results of the elections to council were announced. The following were elected to Council for a three year term: Dr Ranjit More (Blackpool Victoria Hospital) Dr Helen Rimington (St Thomas’s Hospital) Fay Ahmad (Wolverhampton Hospital) Thanks were extended to all those who stood for council election, but had not been successful on this occasion.

Number of current members 2425 6. Changes to BSE constitution In 2002 BSE changed to a Limited Company. In 2008 it was recently been discovered that the process had not been fully completed and members were unable to vote on the proposed changes last year.

The lawyers have now completed the necessary paper work and this has been sent to every BSE member by post.

Vote to accept new changes Proposed: Dr Rick Steeds, Seconded: Dr Mark Monaghan Passed nem con 7. Treasurers report – Graham Leech Draft Accounts were shown and approved.

The BSE financial year has changed to align with the BSE subscription year (April to March).

BSE continues to generate income from the accreditation process as more members sit the examinations; however, the administration costs of EBS continue to rise.

In the past BSE has gained interest from money in the bank but at present when interest rates are very low the society may have to consider others methods of investment.

The ECHO supplement runs at a loss but the society sees this as an accepted service to its members.

In 2008 more money was spent on BSE travel awards.

The lawyers fees needed to make the final changes to the constitution were high, however the society is financially doing well with a balance of £312,656.

500k plus.

The treasurer is making enquiries about gift aid and a rough estimate from the AGM was ~3:1 of members declare BSE fees on their tax returns PA G E 34

8. Motion to re appoint It was proposed to appoint a new accountant – Philips, Kobbs and Co Proposed: Nav Masani Seconded: Dr Guy Lloyd Vote: 2 against, 93 for.

9. Questions from the floor in regard to the published committee reports Committee reports published in September edition of ECHO Accreditation committee – Chair: Dr Ranjit More Communication committee – Chair: Jane Graham ECHO – Editor: Dr Gordon Williams Education Committee – Chair: Dr Rick Steeds Financial Report – Graham Leech No questions were raised 10 Any other business Thanks were given to Graham Leech who is standing down as Honorary Treasurer. Tracy Ryan will take up the post of Treasurer from this meeting.

BSE acknowledged the huge amount of work and time that Graham had given to the society since it began in 1990. No other one individual and done more over the period of time.

BSE thanks Harry Hindle, Dawn and Ingrid for all their hard work in making the annual conference another huge success.

The winner of the best Scientific Abstract 2009 was announced as Dr McIntosh, Eastbourne Hospital.

11. Presidents Report – Simon Ray BSE has been involved with many projects over the last 12 months Accreditation: The TTE and TOE processes have been updated and the new syllabi are now complete and will be available on the website after the meeting.

The European Association of Echocardiography has introduced paediatric accreditation and BSE members, who in the past have held paediatric accreditation, will be able to apply for re accreditation. BSE will be contacting these members shortly.

BSE has worked closely with the ICU society with regards to the FEEL accreditation process.

Departmental Accreditation is led by Helen Rimington. The British Heart Foundation have offered a grant of £50,000 to get a web based application launched. It is suggested that departments would be able to perform Quality Assurance online in the future.

IT – BSE has invested money in redesigning its IT. This will improve communication between the society and its members. The society has also bought new PC’s for the administration office.

12. New Presidents Address – Nav Masani Thanks were given to Simon Ray for the huge energy he has given to the society over the last 2 years. He has completed the transition from a keen and active society into a professional organisation that is now well respected by various bodies including the Department of Health and the British Heart Foundation.

BSE is a leader in the field in accreditation; this is now embedded in our practice. Other organisations are now taking this on but BSE is well ahead of the game and already has processes in place for reaccreditation in both TTE and departmental accreditation.

The vision for the next 2 years is to continue to work with the Department of Health on MSC (Modernisation of Scientific Careers).

Training continues to be an important role of BSE and this will continue drawing on the experiences of previous past presidents and through the council and committees.

The BSE is keen to attract new blood to its committees and welcomes anyone who is interested.

BSE wants to improve communication with its members and work will continue to improve the website.

Simon Ray closed the AGM at 15.10.

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 35

2010 ANNUAL GENERAL MEETING AGENDA Notice is hereby given that the Annual General Meeting of the British Society of Echocardiography, a Company Limited by Guarantee, will be at 14.30 – 15.00 on Friday 29th October 2010 at the Bournemouth International Centre.

Any member of the Society, in good standing, whether or not attending the meeting is entitled to attend and vote at the AGM. The agenda will be as follows: 1. Apologies for absence 2. To receive the Minutes of the 2009 AGM and approve them 3. Matters arising from the 2009 AGM minutes not dealt with elsewhere 4. Notification of Deaths 5. Society activities Workforce development Links with other societies • MSC • Paediatric Re-accreditation 6. Honorary Secretary’s Report Election of new council members Membership summary 7. Motion to make changes to the constitution 8. Honorary Treasurer’s Report To approve the 2009 -2010 draft accounts • New accountant update • Investment of BSE funds • Continued Education fund 9. Motion to appoint/re-appoint Company Auditor/ Independent Financial Examiner Bank of Scotland as Bankers Company Lawyers 10. Questions from the floor in regard to published committee reports Accreditation Committee Communications Committee Education Committee Financial Report 10. Any other business Members may raise any other business not covered else where in the Agenda.

To ensure an accurate reply, any questions to be raised must be notified to the President at least 48 hours prior to the AGM PA G E 35

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 36

COURSES DIRECTORY 2010/11 Details of courses/meeting for the 2010/10 academic year are available online via www.bsecho.org There are two quick and easy routes to finding a suitable course, each accessible from the home page.

1. Events Calendar – use this page to find courses running at a particular time of year. You can search by week, month or year.

2. Training Courses – use this page to search for courses sorted by category i.e. Congenital Courses or 3D Courses.

Cardiac Physiologist – Australia Company Background - Perth Cardiovascular Institute is one of Western Australia’s largest private cardiology service, which provides comprehensive cardiovascular assessments, treatments and intervention services to clients.

The Role - Reporting to the Senior Cardiac Physiologist, this fulltime role is responsible for maintaining the PCI image of a premier cardiovascular service provider by providing professional customer service, accurate correspondence, reports and testing.

The Ideal Candidate - The successful candidate will be have a BSc. Clinical Physiology or equivalent and post grad work experience in Cardiac Physiology. The ability to obtain accreditation and membership with the Australasian Sonographer Accreditation Registry (ASAR) is essential. Experience in adult transthoracic, stress and transoesophageal echocardiography will be well regarded.

Salary will be negotiable and experience based. Reasonable relocation and visa assistance shall be provided to the successful candidate.

New courses can be added to the online directory at any time during the academic year, so check regularly if you are looking for a suitable course.

If you wish to include an upcoming course in the online directory please contact Dawn Appleby on 020 7345 5185 or admin@bsecho.org. All echo related courses are welcomed.

PA G E 36

*To be successful, the candidate will be required to provide evidence of claimed qualifications or experience.* How to Apply - An application containing a cover letter, a resume and referee details should be submitted by the 15th October 2010 to apply@requisitehr.com.au.

Location Information - For information on Perth and Western Australia please refer to: http://www.westernaustralia.com

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 37

DEPARTMENTAL ACCREDITATION LOGO COMPETITION WINNER The British Heart Foundation is supporting the BSE departmental accreditation web project and their graphics team kindly agreed to judge our logo competition. Dr Rachael James (a cardiologist from the artistic hub of Brighton) was the undisputed winner. Our new logo is already an integral part of the new Departmental Accreditation web site. Why not take a look at www.accredityourdepartment.org ?

The logo is an easily recognised quality mark showing that a department has achieved BSE recommended standards. Later this year it will be available for accredited centres to display on letters and appointment cards and newly designed departmental accreditation certificates incorporating the logo are in development.

BSE president Nav Masani congratulating Rachael James on winning the departmental accreditation logo competition

PA G E 37

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 38

Imaging Myocardial Mechanics: Tissue Doppler, Speckle and 4D Sixth Annual Meeting

A “hands-on” course: • Basic principles • Deformation imaging

Imaging myocardial mechanics: TDI, speckle and 4D 6th annual Course 9 - 10 November 2010 Moat House Hotel, Stoke on Trent

A residental hands-on course: – With a special emphasis on selection for device therapy in heart failure – Small group practical sessions – Expert faculty – 4 BSE re-accreditation credits Contact: enquiries@midlandsecho.com www.midlandsecho.com Tel: (01782) 553550 We are grateful to GE Healthcare for their support of this course

Echo in Acute Care The FATE protocol

• Dyssynchrony imaging • Practical image acquisition • Dataset interrogation

Moat House Hotel, Stoke-on-Trent 9 - 10 November 2010

Full Details : www.midlandsecho.com enquiries@midlandsecho.com 01782 553550 High quality echo educational courses from University Hospital of North Staffordshire

Fourth Annual Meeting

ADVANCED ECHOCARDIOGRAPHY

A “hands-on” course aimed at noncardiologists Topics include LV function assessment, valvular disease and effusions Presented by two consultant echocardiologists Supported by GE Healthcare

Moat House Hotel, Stoke-on-Trent 12-13 February 2011 Full Details : www.midlandsecho.com enquiries@midlandsecho.com 01782 553550 High quality echo educational courses from University Hospital of North Staffordshire PA G E 38

An intensive / up-to-date course for the intermediate or advanced level sonographer who wishes to expand and consolidate their current working knowledge of echocardiography in clinical practice.

Moat House Hotel Stoke on Trent

16-18 March 2011 9 BSE reaccreditation points awarded Contact: enquiries@midlandsecho.com www.midlandsecho.com Tel: (01782) 553550 We are grateful to GE Healthcare for their support of this course

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 39

PA G E 39

BSE_ECHO_No71 BS Single

13/9/10

16:59

Page 40