newsletter

incorporat ing the BSE NEWSLETTER

SEPTEMBER 2010ISSUE 71

Aff i l iated to the Br i t ish Cardiovascular Society

CONTENTS include:Audit of Portable Echocardiographic Studies6 - 7Mechanical Index - relevance to contrast8The Role of The Consultant Echocardiographer9 - 10NEW GUIDELINES - Suspected PulmonaryHypertension11 - 14CASE REPORTS15 - 25BSE at BOURNEMOUTH19 - 212010 AGM Agenda36

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CONTENTSSEPTEMBER 2010ISSUE 71

ECHO 2009/10 BSE COUNCIL MEMBERSOFFICERSPresident: Dr Navroz Masani University Hospital of WalesImmediate Past President:Dr Simon Ray Wythenshawe Hospital, ManchesterHonorary Secretary:Jane Allen York District HospitalHonorary Treasurer:Tracy Ryan Cardiac Network liaison for Birmingham,

Sandwell & SolihullELECTED MEMBERSFarhanda Ahmad Heart and Lung Centre,

WolverhamptonDr P Rachael James Royal Sussex County HospitalDr Graham Leech LondonDr Guy Lloyd Eastbourne DGHDr Ranjit More Chair Accreditation Committee

Royal Victoria Hospital, BlackpoolKeith Pearce Wythenshawe Hospital, ManchesterDr Helen Rimington St Thomas’s Hospital, LondonJude Skipper Queen’s Hospital, EssexDr Rick Steeds Queen Elizabeth Hospital, Birmingham CO-OPTED MEMBERS (1 year term)Dr Donna Greenhalgh ACTA Representative

Wythenshawe Hospital Jane Lynch Wythenshawe Hospital, ManchesterDr Muttucumarasamy Mahendran Primary Care

Representative, Milton KeynesDr Mark Monaghan BHF Liaison, Kings College HospitalEamon Murtagh SCST Representative Royal Hospital

for Sick Children, GlasgowDr Bushra Rana Papworth Hospital, Cambridge Claire Seal Industry RepresentativeDr Lindsay Smith Jr Dr Representative,

Queen Alexandra Hospital, Portsmouth

Dr Gordon Williams ECHO EditorLeeds General Infirmary

Page 4 Presidents MessagePage 5 Front CoverPage 6 - 7 Audit of Portable Echocardiographic StudiesPage 8 Mechanical Index - relevance to the use of contrastPage 9 - 10 The Role of The Consultant EchocardiographerPage 11 - 14 New Guidelines - Suspected Pulmonary HypertensionPage 14 Diastolic Dysfunction and AgePage 15 - 25 Case ReportsPage 19 - 21 BSE at BournemouthPage 26 3D Speckle Tracking - A New Era for Echocardiography

and Myocardial Imaging?Page 27 ECHO Cryptic CrosswordPage 28 - 30 Letters to the EditorPage 31 BSE Accreditation UpdatesPage 32 - 33 Committee ReportsPage 34 2009 AGM MinutesPage 35 2010 AGM AgendaPage 36 Courses Directory 2010/11Page 37 Departmental Accreditation Log Competition Winner

INSTRUCTIONS TO AUTHORSECHO is published four times per year. It is the official publication of the British Society of Echocardiography the contact addressis: BSE Administration, Docklands Business Centre, 10-16 Tiller Road, Docklands, London E14 8PX, Tel. 020 7345 5185, Fax 0207345 5186 Email [email protected]. 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: [email protected] and copied [email protected] . 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 howevershould be restricted to encouraging further reading and not be comprehensive. References to commence with normally the first twoauthors, 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 BritishSociety of Echocardiography (BSE). Official BSE council views or statements will be identified as such.

Information in respect of advertisements can be obtained from [email protected] .

Editor


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PRESIDENT’SMESSAGE

The coalition government’s White Paper “Equity andExcellence: 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 ofits NHS in 2009-10).

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

“Liberating the NHS” sees the abolition of the currentcommissioners - Primary Care Trusts – within the next twoyears. Relevant to those working in secondary and tertiaryservices, the Strategic Health Authorities will also bedismantled. A further document, “Commissioning for Patients”provides further details on the intended roles andresponsibilities of the GP consortia and NHS CommissioningBoard – it also seeks views on a number of specific consultationquestions.

Initial thoughts are dominated by the prospect of the majordisruption that may ensue in secondary and tertiary care, wheremost cardiologists and echocardiographers work, as a result ofsuch a radical upheaval. Furthermore, it seems inevitable thatthe new commissioners will require time to mature and develop,during which prospects of service development or expansionseem slim. It is fair to say that there are equal concerns inprimary care, amongst GP’s who will be responsible fordeveloping the new consortia. Specific detailed responses to theconsultation document are being prepared by the Royal Collegeof Physicians and the British Cardiovascular Society, amongstmany others. BSE is in a position to contribute to the BCSresponse, through our representation on its Executive.

It is too early to understand the full implications for ourEchocardiography departments and the BSE. The roles ofprofessional societies, such as BSE and BCS, as well as theother affiliated groups BCIS, HRUK and PCCS, will includeadvising the National Commissioning Board (if possible) onquality and standards, to ensure that cost reduction does notoverride clinical standards. Discussions at BSE Council, as wellas BCS Executive, will have taken place by the time you readthis, and more detailed analysis and commentary will follow infuture editions of ECHO. Comments and opinions are requestedfrom BSE members who have any interest or knowledge ofrelevance.

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

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

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

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

On page 25 of this edition of ECHO you will see that we areinviting nominations for new members of Council for a threeyear term. As always the Council is made up of members of theSociety, who are active and wiling to be involved in theadvancement of echocardiography and BSE as a Society.People like you. Becoming a member of Council is an idealopportunity to make sure your voice and local (national)concerns are heard.

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

Enjoy this edition of ECHO, which as usual, has a multitude ofinteresting articles and case studies, many submitted bymembers.

I look forward to seeing you in Bournemouth.

Nav

IMEDIX SIMULATORS

We are delighted to announce thatVimedix (CAE Healthcare) will be joiningus in Bournemouth to host the Satellitesession on the evening of Thursday 28th

October.

If you will be arriving early inBournemouth, or staying following the

Core Training, FEEL or Accreditationexams, why not join us 19:30 – 21:00?

No registration is required and the ses-

sion is free to attend. A buffet and

drinks will be available to all attendees.


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FRONT COVERThere are no prizes for identifying the front cover image of thisedition of ECHO. The patent ductus arteriosis is clearlyapparent imaged from the super sternal notch. The imageidentifies the distal aortic arch, the left subclavial artery, thedescending aorta and the ductus identified by colour flow. Theductus, 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 connectingthe pulmonary artery to the aorta diverts much of the pulmonaryarterial flow to the descending aorta. Within hours of birth andrespiration commencing patency of the ductus is no longerrequired. The ductal tissue constricts occluding it as a vesselthereafter fibrosing there being no longer a vascular connectionbetween the pulmonary artery and aorta. As with mostbiological systems, normality does not always occur and theductus can remain open, i.e. a so called patent ductus arteriosus.With the regression of neonatal pulmonary vascular resistanceand the fall of pulmonary arterial pressure, in the presence ofthe higher systemic vascular resistance, if the ductus remainspatent the flow becomes aortic to pulmonary artery i.e. left heartto right heart or simplified to “left to right shunt”. In infants theductus and its shunt can be large, overloading the right heart,closure of the ductus then being required. Today this can beachieved pharmacologically but may still require surgicalligation or in older children by catheter techniques of plug oroccluder device.

The ductal tissue may partially constrict, resulting in a smallshunt, or only a very small unmeasurable shunt. Even a smallshunt is usually identified by its typical physical signs,principally that of a continuous or “machinery” murmur onauscultation (running through systole and diastole). It isunfortunately the case that current auscultatory skills are suchthat this type of murmur may be missed or misinterpreted in anadult hence the presence of a small ductus still being present inadult life may remain clinically undiagnosed.Echocardiography is the optimum imaging technique to identifythe presence of a small ductus.

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

pattern. The reasons for this are that a) in most adult studies thecolour box is positioned around the pulmonary valve but notextended far enough along the pulmonary artery to detect colourductal flow which enters near to the pulmonary arterialbifurcation to left and right pulmonary arteries so it is missed,and b) the saw tooth flow pattern which only occurs when thereis a significant left to right shunt, so when a small patent ductusexists the diastole pulmonary flow is too small to create thatflow pattern.

Additional points to mention in respect of ductal patency relateto anatomical changes with advancing age. The aortic end ofthe ductus is usually wider than the entrance to the pulmonaryartery, that is the ductus is tapered from a larger to a smallerdiameter. This creates a venturi effect, accelerating the flowvelocity creating a degree of turbulence. As with any other ‘jet’lesions, the jet turbulence creates a site for the development ofendocarditis. Endocarditic vegetations develop at thepulmonary artery end of the ductus and can break off into thelungs resulting in pulmonary abscess formation, hence ductalendocarditis is a grave condition. It is for this reason and notfor the degree of shunt that small patent ducts are electivelyclosed. Another age change is that of calcification whichoccurs in adult patent ducts. Today the persistence of a largeductal shunt is virtually always identified in infancy orchildhood it would be extremely rare to find now in an adult butif present could be a cause of pulmonary hypertension.

Having given the above description in respect of patent ducts,

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 beensurgically ligated (but not divided) has not been completely tiedoff leaving a small way through (this is today a rareoccurrence).

However for those of you who may practise veterinaryultrasound, patent ducts are relatively common in certain breedsof dog, notably Poodles, Collies and Shetland sheep dogs.There is some evidence of an inherited trait in these dogsalthough inheritance in humans is not clear but an incidence of3% is said to occur in siblings of those with patent ductus.Purely out of interest patent ducts are also relatively frequentlyfound in pigeons and pigs!

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

Gordon Williams, Editor

Left subclavian artery

Aorta

Patent ductus

Pulmonary artery


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AUDIT OF PORTABLEECHOCARDIOGRAPHIC STUDIESIntroduction

The use of portable echocardiography has been validated as partof community screening programmes and as a “point of care”diagnostic tool in acutely ill patients.

Portable echo can provide basic diagnosis in the vast majorityof patients. This includes the assessment of pericardialeffusions, the measurement of the dimensions of cardiacchambers, the identification of valvular pathology and theassessment of ventricular function.

Portable echocardiography has the same limitations as standardecho (e.g. difficult windows in patients with airways disease orthe severely obese). In addition many of the patients that are toounwell to travel to the Echocardiography department representan added challenge to the echocardiographer (e.g. not possibleto rotate patients on ventilators into a lateral position andsurgical incisions and dressings may obscure precordial orapical windows).

Despite this, and when performed by experienced operators, thesensitivity of portable echocardiography for the detection ofcardiac pathology is higher than that of clinical examination andcan reach 70-90% when compared with standard departmentalstudies.1

A Portable “focused study” limits the examination to answeringa specific question determined by the clinical context. Eventhese limited examinations require substantial training andshould preferably be performed by accredited individuals inorder to avoid diagnostic errors. To illustrate this point a studybased in a north-American ITU indicated that up to 31% ofimportant findings were missed by portable echo whencompared to standard studies.2

The American College of Cardiology/American HeartAssociation/ American Society of Echocardiography3, theBritish Society of Echocardiography4 and the EuropeanAssociation of Echocardiography5 have all producedrecommendations on training requirements. They haveidentified the minimal training that is considered necessary toachieve the skills for performance according to acceptedstandards. Accreditation is however “a minimum requirementand cannot be regarded as a guarantee of competence”.Accreditation tends to consist of log books of studies (150 to250) and practical and written assessments. Currentrecommendations maintain that echocardiographic studiesperformed by inexperienced clinicians should not be used toinfluence the management of patients.

Aims

We conducted an audit of Portable Echocardiographic Studiesundertaken at a large cardiology tertiary referral centre inLondon. We aimed to quantify the number of studies beingcarried out outside the echocardiography department and toidentify the indication for portable scanning. The quality ofimages obtained and the quality of the reports being issued werethen retrospectively analysed. We aimed to prompt reflection oncurrent clinical practice and to facilitate continuous qualityimprovement.

Methods

All echos carried out using the portable machine (Siemens X300) between 03/02/2010 and 26/02/2010 were audited. Thestudies were then uploaded to the hospital’s echocardiographyimages management and reporting system (PROSOLV,FUJIFILM Medical Systems U.S.A., Inc.). They were thenanalysed in the department by either a consultant in cardiologywith a special interest in imaging or by the principalechocardiographer. The reports were retrospectively collectedfrom the clinical notes and reviewed in the department.

Results

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

Therefore only 49 studies were fully reviewed and included inthe audit.

80% of studies were carried out by Cardiology SpRs (39 / 49).16% of studies performed by SHOs (8 / 49) and 4% carried outby SHO under supervision of SpR (2 / 49).

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

Figure 1. Location of Portable studies

Indications for the echo varied widely. The major groupsinclude patients that had suffered an acute Coronary Syndromeor were post-STEMI. The third largest patient group includedpatients admitted for an urgent inpatient CABG procedure.

Figure 2. Indications for Portable Echocardiography


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The quality of the images obtained for the studies were thenranked from A (illustration quality) to F (non-diagnosticstudies):

Assessment of Images Obtained

Quality A All valves of illustration quality, 100% of endocardial definition , allwindows 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 ormisinterpretation with unequivocal potential for seriousmorbidity 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%

Figure4. Departmental Assessment of the Report Issued

Conclusion

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

None of the audited echos had been uploaded to the hospital-wide echocardiography database system and could not thereforebe easily reviewed by the medical staff making decisions aboutpatient management. Since this audit was presented thetechnical issues related to the uploading of images have beenresolved and this now happens routinely and automatically.

In 7 out of the 73 studies initially identified no report was foundin the notes. This raised the question of some studies not beingformally reported. At a departmental meeting, where this auditwas presented, the SpRs and SHOs were reminded that anyecho assessment (even “quick look” scans) that affects patientmanagement must be recorded and reports documented in thenotes.

Analysis of the data collected allows us to conclude thefollowing: 49 % of all studies (24 / 49) of quality A, B, or C -all valves visible and studies of diagnostic quality. The qualityof studies in this audit falls below departmental standard (39%of scans of Quality E - Two ill-defined valves and/or <50 % ofendocardial definition and/or at least two non-obtainablewindows) but the patient population is more challenging (e.g.8% of patients in ITU, 15% post cardiothoracic surgery, manyacutely unwell).

The quality of reporting was generally good with 77 % (38 / 49)of reports of category 3, 4 or 5 (No or minimal disagreementswith original report). No gross errors in reporting wereidentified. However 18% of reports (9 / 49 echos) had reports ofCategory 2 (definite omission or misinterpretation of findingswith strong likelihood of moderate morbidity but no threat tolife). This highlighted the need for scans to be discussed with anexpert where any doubt remains. If necessary scans should berepeated and if possible be carried out in the department. TheCardiology registrars were also encouraged to issuecomputerised reports of the portable studies. These should bedone in the Echo department where a second opinion andfeedback can easily be obtained.

Following our recommendations a registry of all the portablescans that are carried was started. This will facilitate continuousaudit and assessment and is a practise we recommend to allusers of portable echo.

Dr. Antonio de Marvão, Professor Petros Nihoyannopoulos

Hammersmith Hospital, London

References

1 Ashrafian H, Bogle RG, Rosen SD, et al. Portableechocardiography. BMJ. 2004 Feb 7;328(7435):300-1

2 Goodkin GM, Spevack DM, Tunick PA, Kronzon I. Howuseful is hand-carried bedside echocardiography in criticallyill patients J Am Coll Cardiol 2001;37: 2019-22

3 Quinones MA, et al. ACC/AHA clinical competencestatement on echocardiography: a report of the AmericanCollege of Cardiology/American Heart Association/AmericanCollege 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


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MECHANICAL INDEX –and the practical relevance to the use of contrastWith transpulmonary contrast now part of everyday life for theechocardiographer, it is common knowledge that the ultrasound ‘power’otherwise known as the ‘mechanical index’, has to be turned down tooptimise contrast enhanced images. Why?If the transmitted acoustic power is very low, the returning signal afterhitting ultrasound contrast bubbles is similar to the transmitted. If thesignal power is turned up a little, to a low setting perhaps 0.10MI(mechanical index), the bubble is excited and oscillates non linearlyresulting in the return of the fundamental frequency and a secondharmonic signal. If the power is turned higher the returning signal isthe fundamental together with several harmonic signals. Finally, if thetransmitted power is turned even higher the contrast bubbles areagitated to such an extent that their capsule bursts and the contrastsignal enhancement benefit lost (often recognised as contrast‘swirling’).

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

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

Ultrasound waves are generated by the electrical excitement of a piezoelectric crystal the oscillation of the crystal transmitting waves intotissue and awaiting their return to descramble then back into electricalsignals. Think of the waves as pressure waves even though they aretermed ultrasound waves (as that term just describes the frequency ofthe waves). The transmitted waves have a positive and negativepressure component (as per Fig 1). As the waves traverse body tissuethey cause some heating or temperature rise of that tissue, referred to asthe “thermal index” of the transmission. The positive and negativepressure waves move the tissue components and therefore cause amechanical change referred to as the “mechanical index” of thetransmission. The combined indices are referred to as “acousticoutput”. The situation is always somewhat more complicated than abrief description allows as peak positive and negative ultrasoundpressures can vary with different modes of ultrasound e.g. a single M-mode line or a wider real time sector with differing frequencies oftransmission, pulse repetition and pulse duration. “Thermal index” is oflittle concern in echocardiography compared to other types ofdiagnostic ultrasound in that it is considered that the blood traversingthe cardiac chambers and myocardium acts as a cooling agent. It ismore applicable to scanning static structures. With high mechanicalacoustic pulses i.e. repetitive positive and negative pressure pulsestheoretical 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 mainlyconcentrated on the negative component of the pressure wave of thetransmitted pulse as the ‘negativity’ or ‘suction’ can result in causing orcreating ‘cavities’ or enlarging cavities in tissues and consequentlycause tissue damage by further “cavitation”.

Most of the scientific evidence for inducing tissue damage comes fromanimal experiments e.g. recognising extravasation of blood from mouselungs which occurs with an M.I. of in excess of 0.6 M.I. Interestinglywhen I looked up more of this type of research on the harmful effects ofultrasound it had been demonstrated on insects, fruit flies (whateverthey are) and so called “lower animals”. It seems that if somecavitation already exists then the acoustic pressure of ultrasound will bemore easily detrimental. Anyway, all the theory has been interpreted toimpose an upper limit on “Mechanical Index” (M.I.) for diagnosticultrasound of 1.9 as exceeding it may become close the threshold fortissue damage.

What the outputs were up until 1976 I haven’t found listed, as it is notthe data manufacturers would then publish however it is now acceptedas a requirement that echocardiographic equipment displays the outputas the “mechanical index”. Unless you are really into physics I doubt ifanyone can remember in the long term the definition of “mechanicalindex” so here goes, it is “the derated peak rerefractional pressure inmegapascals (1 Mpa being approximately 10 atmospheres) at the pointof maximum pulse intensity integral, divided by the square root of theultrasonic centre frequence in Megahertz” – so there

The relationship can be simplified to MI =

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

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

In addition to displaying the M.I., current equipment allows the operatorto control power (M.I.) up or down. Increasing the M.I. will give morepenetration and improve resolution (but the level of M.I. used should bebalanced to give the optimum information with no point in increasing ithigher than the optimum image).

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

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

Returning to the negative pressure component of the transmitted signaland its direct relationship to power (MI) whereby the negative pressureresults in creating cavities it can now be clearly seen how high imagingpower increases bubble oscillation and expands their cavity until theshell or capsule of the contrast bursts or collapses. The experimentalwork 30 years ago (before gasses were encapsulated to form imagingcontrast bubbles) observing how transmitted ultrasound “blew up” orexploded insects or fruit flies by expanding their cavities now hasrelevance and makes increasing contrast bubble cavities until they blowup and are destroyed hardly surprising and very understandable.

Contrast agents with diatomic gases (e.g. air, O2, nitrogen) are morevulnerable than larger molecules (e.g. CO2 or fluorocarbons) as they aremore prone to violent cavitation in a given acoustic field (although thereis the additional effect of the bubble shell or capsule which caninfluence this). Thus in addition to size, imaging contrast bubbles arefilled with fluorocarbons and not air for stability to enable them toremain intact for long enough to traverse the lungs

What may have appeared irrelevant research blowing up fruit flies yearsago has now come to fruition and is very relevant to current ultrasoundcontrast imaging.

I will write a further related article building on the above informationdescribing high and low MI imaging, power modulated imaging andother related but often confused terms in a subsequent edition of ECHO.

Gordon Williams

Editor

PNAP

frequency√

Pressure

+ Ve

- Ve

Amplitude

PNAP


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Modernising Scientific CareersClinical Cardiac Physiology is one of 51 disciplines in theHealthcare Science Workforce that is being modernised and isunder scrutiny for state registration. The DoH have recognisedthe importance of the Healthcare Science Workforce whichconstitutes 5% of the total healthcare workforce in the UK.Almost 80% of all diagnoses made are a result of their work. Inmodernising the health service the DoH have recognised theimportance of the consultant healthcare scientist role which willprovide:• 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 andprovision.

• 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 aconsultant post and found the funding then the post has to beapproved 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 forparticular organisations and the proposer.

• Background information in support of the development of thepost including, policy content, health needs assessment, keystakeholders and strategic partnerships, impact on patientcare, service development , links with regional networks suchas cardiovascular/cancer/diabetes etc.

• A draft job description, person specifications and job planincluding 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 RoleOn the National Framework there are 4 Core Functions thatexemplify the consultant role to achieve quality serviceprovision and better outcomes for patients:

1) Expert Clinical Practice2) Education and Professional Development3) Research, Audit and Evaluation.4) Leadership

THE ROLE OF THE CONSULTANTECHOCARDIOGRAPHERThe concept of a Consultant Echocardiographer is not wellrecognized in NHS Trusts across the country. Raising awarenessof this important and much needed new role is essential toimprove career development for echocardiographers who wishto pursue an academic and purely scientific career as analternative to management to reach the top of the career ladder. Such posts require individuals to deliver specialist clinicalservices, which exceed existing grading criteria and cannot beappropriately rewarded or recognised under the current gradingstructure. In the technically challenging and rapidly expandingfield of echocardiography these posts should improve thequality in echo service provision and contribute to educationand echocardiography research.

BackgroundIn1998 and the labour government were in power. The PrimeMinister Tony Blair first described the concept of a nurseconsultant and announced a national strategy for consultationinto developing this new job profile. He announced that thiswas a “career opportunity for expert, highly experienced nurseswho wished to remain in clinical practice.” The first nurse consultant posts were funded by the Departmentof Health in 1999 and were appointed in England in January2000. Further nurse consultant appointments in NorthernIreland in September 2000 followed an announcement from theminister of health, social services and public safety stating “Theestablishment of these groundbreaking posts will help developour health services and provide clear development opportunitiesfor nurses. For the first time, nurses can keep up their day-to-day contact with their patients, in wards and in the community,and yet still progress in their careers.” April 2001 saw theappointment of nurse consultants in Wales.In 2004 the first consultant posts in the Allied HealthcareProfessions were appointed and included radiography,radiotherapy, physiotherapy, speech therapy and dietetics, allstate registered professions . The first breakthrough for non-registered healthcare professionals in clinical cardiacphysiology came in 2006 to echocardiography , with theappointment of the first Consultant Echocardiographer inLeeds. Currently there are less than a handful of such posts inthe United Kingdom.

Training as a ConsultantAt present, postgraduate diploma, MSc or PhD level academiceducation, professional education and training plus at least 5 yrspost qualifying experience are an essential requirement and thegateway for a consultant post. For those without thisprerequisite qualification other factors may be taken intoaccount such as recognition by peers, length of clinicalexperience, personal qualities, professional activities and status.In the near future modernising scientific careers will supportachievement of this level of academic education by followinga specific career pathway. This allows entry point at a registeredhealthcare scientist level with competitive entry on to higherspecialist scientist training leading to a MSc qualification. Likecardiologist or other consultant posts , these consultant postswill be competitive and can be applied for only after completionof this training.


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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 corefunctions• 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 improvementof service delivery .

• Working in partnerships in different ways to take newinitiatives forward.

• Develop and apply leadership skills to engage in innovativeand exciting research projects. Freedom to pioneer and crossboundaries.

• 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.

• Keeping up to date with central policy initiatives and takingthem 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 therole of the Consultant Echocardiographer . A personalevaluation suggests that this role needs to happen for the rightreasons and not just to meet personal aspirations. Such a roleshould stem from service need and aim to fill gaps inechocardiography service provision. It should not be used as acost-saving exercise to replace the consultant cardiologist withspecialist interest in Echocardiography. A supportive nurturingenvironment is important to ensure success of the post.Professional and personal support are mandatory because dueto the innovative nature of the role there is risk of isolation. Therole is beneficial to echo service development as it provides areadiness to cross traditional boundaries in echocardiographypractice as well as education. For the post holder it providesincreased job satisfaction, strengthens leadership within theprofession, provides an opportunity to make a difference to theprofession, 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 AhmadConsultant Echocardiographer

References• British Cardiac Society. Cardiac workforce requirements in

the UK, April 2004. www.bcs.com/download/221/BCS-Cardiac-Workforce-2004.pdf

• Department of Health (2000) “Alan Milburn announces firstnurse consultant posts”, www.dh.gov.uk

• Department of Health (2001) “Empowering the frontline-more NHS nurse consultants”, www.dh.gov.uk

• Department of Health (2000) “Health secretary announcesninety-one new nurse consultant posts”, www.dh.gov.uk

• Dewing, J. (2003) “A mode24/05/2010 15:28l for clinicalpractice within the nurse consultant role”, Nursing Times,Volume 99, No.

• Fifth report on the provision of services for patients withheart disease. Heart 2002;88(Suppl 3):iii1–56. 76

• Lipley, N. (2000) “Survey finds consultant nurse posts hard tofill”, Nursing Standard, Volume 15, No.2

• Manley, K. (1997) “A conceptual framework for advancedpractice: an action research project operationalising anadvanced

• McKenna HP, Cutcliffe JR, McKenna P. PhD or DNSc: Whatcontribution to the substance of Nursing? All Ireland Journalof Nursing & Midwifery; Vol 1, No 2, 55-58

• Modernising Scientific Careershttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@abous/documents/digitalasset/dh_113200.pdf

• Office of the Chief Nursing Officer, Welsh AssemblyGovernment, (2003) “Evaluation Tranche 1-Nurse/midwife/health visitor consultant posts“

• Practitioner/Consultant role”, Journal of Clinical Nursing,Volume 6, 179- 190


PA G E 11

NEW GUIDELINESA Guideline Protocol for the Assessment of Patients with Suspected PulmonaryHypertension.

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 12

VIEW

PLAX

A4CH

A4CH

PSAX

Modality

2D

2D

M-mode

2DM-mode

Measurements

RV:LV DiastolicRatio

• Qualitative

• Identify pericardialeffusion as a markerof adverse prognosis

RV Minor/MajorAxis Dimensions(RVd)

• Quantitative

RV Diastolic andSystolic Area(RVAd/s)

• Quantitative—calculate FractionalArea Change1

Tricuspid SystolicAnnular PlaneExcursion (TAPSE)

• M-mode cursoracross lateraltricuspid annulus• Select a fast sweepspeed.• Measure totalexcursion of thetricuspid annulus

Inferior Vena CavaDiameter (IVC)

• At end diastoleand end-expiration.• Perpendicular tothe IVC long axis.• Approx1.0 – 2.0cm from the RAjunction.• Assess % reductionin diameter withsniffing.

Explanatory Note

RV:LV ratio cutoff >0.5:1

• Significance: Diagnostic• An assessment of RV enlargement

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

TAPSE cutoff <1.6 cm

• See BSE Guidelines: ChamberQuantification• Significance: Diagnostic• A measure of longitudinal RV systolicfunction2

See BSE Guidelines: ChamberQuantification

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

Image


PA G E 13

A4CPSAX

PSAX

A4CH

PSAX

A4CH

CW

PW

PW TDI

2D

2D

Peak tricuspidregurgitant velocity (TR Vmax)

RV outflow tractacceleration time(AT)

Held end-expirationOnset of flow topeak velocity

Isovolumetricrelaxation time(IVRT)

• Sample volume atbasal lateral RVmyocardium• Held end-expira-tion• Offset of S’ waveto onset E’ wave

Eccemticity Index(EI)

EI = D2/D1

Where:D1 = Minor axisdimension perpendi-cular to septum

D2 = Minor axisdimension perdendic-ular to D1

RA Volume (RAV)

Where:RAV=0.85(A2)/L

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 theabsence of pulmonary stenosis• Consider agitated saline/air/blood con-trast if incomplete envelope 5

RVOT AT cutoff <105 ms

• Significance: Diagnostic 6

• Surrogate measure of PA pressure

RV IVRT cutoff >75 ms

• Significance: Diagnostic. A value below40ms has a high negative predictive valuefor PHT 7

• A measure of RV dysfunction.

EI cutoff >1.0

• Significance: Prognostic 8

• EI end systole an expression pressureoverload• EI end diastole an expression volumeoverload

RAVI male cutoff >33 m/m2

RAVI female cutoff >27 ml/m2



PA G E 14

A4CH

A4CH

PW TDI

PW TDI

RV S’ WaveVelocity

• Sample volume atbasal lateral RVmyocardium

RV MPI

MPI= a-b/b

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

S’ wave velocity cutoff : <12 cm/s

• Significance: Diagnostic 10

• Expression of RV longitudinal systolicfunction

• RV MPI cut off: >0.32


• Expression of RV systolic and diastolicperformance

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 Cardiol2002;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 AGEThe 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 beconsidered 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 milddiastolic dysfunction such as LA dilatation or aortic rootdilatation/loss of geometry, should we consider that this isabnormal regardless of age?

My main concern is labelling patients as having diastolicdysfunction on reports for consultants who are not cardiologistsor who may not understand the implications of the age factor.

Response

About half of patients with a new diagnosis of heart failure havenormal or near normal global ejection fraction. These patientsare diagnosed with ‘diastolic heart failure’ or ‘heart failure withpreserved ejection fraction’. The assessment of diastolicfunction and filling pressures are integral to the diagnosis of thiscondition and echocardiography is the principal non invasiveclinical tool used for this purpose.

Over the past 25 years, multiple echo parameters have beenproposed for the assessment of diastolic function each with itsstrength and limitations. These measurements can also be used

to grade the severity of diastolic dysfunction into mild or GradeI (impaired relaxation pattern), moderate or Grade II (pseudonormal filling pattern) and severe or Grade III (restrictive fillingpattern). However many of these echo parameters areinfluenced by heart rate, age and loading conditions and mustbe taken into consideration during evaluation.

Normal aging alters the diastolic properties of the left ventricleresulting in abnormal relaxation and compliance. In turn,several of the echo parameters used to assess diastolicdysfunction also change with age. Differentiating these agerelated changes from mild or Grade I diastolic dysfunction(where the LV filling pressures are commonly raised at rest orwith exercise) requires a comprehensive 2D, spectral and tissueDoppler evaluation and using age related cut off values.Although this process is tedious, the distinction is clinicallyimportant as the 5 year mortality in a patient with mild diastolicdysfunction even in the absence of symptoms is five-fold higherthan in subjects with normal diastolic function. Thereforelabelling some one with mild diastolic dysfunction simply basedon age or a reversed E/A ratio without taking into considerationother parameters is not recommended. No single parameter canbe used in isolation. A guideline outlining this and the data setrequired to assess diastolic dysfunction is being developed bythe BSE and will be published in a future copy of Echo.

Dr. Thomas Mathew, Nottingham University Hospitalon behalf of the Educational Committee of British Society of

Echocardiography


PA G E 15

CASE REPORTS1) Incidental finding of inferiorvenacaval tumour with thrombusA 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

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.

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.

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:

1. Preoperative imaging in renal cell cancer. Heindenreich A,

Ravery V; World J Urol. 2004 Nov; 22(5):307-15.

Fig. 1. Subcostal view showing tubular mass arising in the

IVC extending into the right atrium.

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

tumour in to the RA.

Fig. 3a. 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.


PA G E 16

2) Intracardiac pseudotumour:a case of caseous calcificationof the mitral annulusAn 81 year old female presented with shortness of breath andwas found to be in atrial fibrillation with significant mitralregurgitation. The past history included ongoing treatment forhypertension. A transthoracic echocardiogram demonstrated alarge mass in the region of the mitral valve (Figure 1). Thisprojected into an enlarged left atrium and was associated withboth significant mitral regurgitation and left ventricular outflowtract obstruction. A computerised tomographic (CT) scanconfirmed this mass to represent circumferential calcification ofthe mitral annulus. On CT imaging, the structure appeared as anellipsoid shape with a calcified rim. Within this mass, high andlow density regions were identified. It did not enhance on post-contrast CT acquired imaging.

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

women. When the calcification is more extreme, a rare variantoccurs, termed caseous calcification. One of the largest studiespublished, reported on 14 patients with caseous mitral valvecalcification; all 14 were elderly and all hypertensive [1]. In somereports the calcification is described as extending into themyocardium with resultant dysfunction of the subvalavularapparatus and a restrictive cardiomyopathy.

As in this case there is usually a rim of calcium with centralecho lucencies suggestive of liquefaction. When associated withmitral valve dysfunction, cardiac surgery to excise the mass andreplace the valve, with or without ring annuloplasty, has to beperfomed. At surgery, the interior of such structures have beenfound to contain a ‘putty like’ caseous material [2]. A surprisingfeature of this condition includes occasional reports ofspontaneous resolution [1].

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

The features of caseous calcification of the mitral valve annulusare important, in order to avoid diagnostic confusion withthrombus, an enlarged coronary sinus, tumour or abscess.Whilst a benign condition, the physical presence of a large masshas significant implications to the functioning of the mitralvalve. Cardiac CT scanning not only helps diagnose such anintra-cardiac mass, but also to assess its influence on adjacentstructures.

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 clinicalcourse of caseous calcification of the mitral annulus: aprospective echocardiographic study. J Am Soc Echocardiogr2008;21(7):828-833.

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

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

ACCREDITATION TIPAre you collecting cases for your logbook?

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

For resources to help you to do this please visit theAccreditation pages of www.bsecho.org


PA G E 17

3) Emergency sternotomy andaortic valve repair followingperforation by an ablationcatheter

We report a case where a patient underwent emergencysternotomy and aortic valve repair following aortic rootperforation by an ablation catheter.

A 57-year-old female patient presented initially in 2001 with a12 month history of palpitations and breathlessness. Twenty-four hour ECG monitoring revealed paroxysmal atrialfibrillation. She was managed conservatively with medicaltherapy but she remained symptomatic. In 2002 she underwentpulmonary vein isolation. This procedure was unsuccessful andher paroxysmal atrial fibrillation persisted. In 2007 a redopulmonary vein isolation was attempted but it provedimpossible to cross the inter-atrial septum and the procedurewas abandoned. However, she found her symptomsincreasingly disturbing and in April 2009 she was admittedelectively for a redo-redo pulmonary vein isolation.

Due to the failed previous attempt the cardiologistsrecommended transoesophageal echocardiography (TOE)guidance for the procedure but the patient refused. During theprocedure it was noted that the intra-atrial septum was tough.The guidewire was passed successfully across the inter-atrialseptum and this was confirmed by radio-opaque contrastinjection. The contrast appeared in the left atrium and leftventricle following injection. At this point the guidewire wasused to introduce a Baird sheath. After the insertion of theBaird sheath contrast was injected to confirm its position. Thecontrast appeared directly in the aortic root.

Shortly after the insertion of the Baird sheath, the patientbecame haemodynamically unstable with tachycardia andhypotension (HR 132 beats per minute (bpm) and non-invasiveblood pressure (NIBP) 89/45). Urgent transthoracicechocardiography was performed and it revealed a smallpericardial effusion. A percutaneous pericardial drain wasinserted and 100ml of fresh blood was aspirated. The patient’scardiovascular parameters immediately improved (115 bpm andNIBP 110/62). A Cardiothoracic surgical opinion was soughtand it was felt that the patient required surgical exploration torelieve cardiac tamponade and remove the Baird sheath with thepatient on cardiopulmonary bypass. The patient was thereforetransferred to theatre for emergency surgery.

Prior to induction of anaesthesia, ECG and SpO2 monitoringwere established. Under local analgesia, a 14G cannula wassited in the dorsum of the left hand, a 20G arterial line wasplaced in the left radial artery and a four lumen central venouscatheter was sited in the right internal jugular vein. Anaesthesiawas induced in the operating theatre with the surgical teamscrubbed and the perfusionist on standby to facilitate rapidinstitution of cardiopulmonary bypass in the event of refractoryhaemodynamic decompensation. Anaesthesia was induced withmidazolam, remifentanil and rocuronium, and maintained usingisoflurane 1 MAC and an effect site target controlled infusion ofremifentanil. A nasopharyngeal temperature probe was placed,and a transoesophageal echocardiography probe was inserted

easily into the patient’s oesophagus. She remainedcardiovascularly stable throughout induction with a meanarterial pressure greater than 50 mmHg. Following sternotomythe pericardium was opened and 400mls of blood underpressure was evacuated which resulted in immediateimprovement of her haemodynamics.

A standard 20-view transoesophageal echocardiography studywas performed. A mid-oesophageal short axis view at the levelof the aortic valve is shown (figure 1). The Baird sheath can beseen coming from the inferior vena cava, passing through theright atrium and entering the aortic root.

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

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

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

After the Baird sheath was removed a fistula became visiblebetween 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 andgood left ventricular function. The aortic valve was repairedwith a bovine pericardial patch, the fistula was sutured closedand pulmonary vein isolation was performed. Post-operativelythe patient was transferred to the intensive care unit. Herrecovery was uneventful and she was discharged from hospitalseven days later in sinus rhythm.


PA G E 18

Fig. 3. Fistula between the aortic root and right atrium

Discussion

Atrial fibrillation is the most common supraventriculartachyarrhythmia with an incidence of 6% in patients over theage of 65 and increasing to 10% in patients over 85 years old 1.Initiation of atrial fibrillation is most commonly due to atrialectopic beats from ectopic foci. These ectopic foci arefrequently located in the left atrium at the origins of thepulmonary veins 2. Radiofrequency pulmonary vein isolation isused for the treatment of recurrent, drug resistant atrialfibrillation 3. A recent meta-analysis found that pulmonary veinisolation resulted in maintenance of sinus rhythm at one year of77%, 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 majorcomplications, the incidence of which ranges from 2.6 4 to 6% 5.Major complications are defined either as those that requireintervention, or result in prolonged hospitalisation or long-termdisability. Complications include vascular accesscomplications, atrial flutter of new onset (3.7%), pulmonaryvein stenosis of greater than 50% (1.3%), cardiacperforation/tamponade (1.2%), thromboembolic events (0.28%)and extracardiac injury (such as atrio-oesophageal fistulas, peri-oesophageal vagus plexus injury and transient phrenic nerveinjury) 3. A large prospective observational study investigatedrisk factors for the development of complications, whichinclude female sex, repeat procedure, coronary artery diseaseand advanced age (greater than 70 years old) 6. The NationalInstitute of Health and Clinical Excellence produced guidelinesin March 2009 regarding percutaneous (non-thoracoscopic)epicardial catheter radiofrequency ablation for atrial fibrillation7.The guidelines do not mention the use of transoesophagealechocardiography to assist the trans-septal placement of theablation sheath. The risk of major complications in this casewas likely to be higher as the patient possessed two risk factors(female gender and having a repeat procedure).Transoesophageal echocardiography was recommended by thecardiologists but refused by the patient. Currently there are noguidelines as to whether this could justifiably be regarded as acontraindication to performing the procedure.

In the acute setting, cardiac tamponade can be caused by arelatively small pericardial effusion. The classic triad of cardiactamponade is decreasing arterial pressure, increasing venouspressure and muffled heart sounds. This manifested itself ashypotension, tachycardia and a raised central venous pressure(CVP). The effusion causes impairment of biventricular fillingalthough intrinsic ventricular function is unaffected. The result

is a relatively fixed and low stroke volume with elevated venouspressures and cardiac output is almost entirely rate dependent.Affected patients are at high risk of fatal haemodynamicdecompensation following induction of anaesthesia due tofurther myocardial depression, vasodilatation or bradycardia.The maxim ‘fast, full and tight’ has been used to describe thehaemodynamic targets which represent the optimum in thesepatients. Anticholinergic agents and vasoconstrictors are useful;inotropic agents are not.

Conclusion

Pulmonary vein isolation is an effective treatment for recurrentdrug resistant atrial fibrillation but it is associated with majorcomplications. The risk of major complications in our case waslikely to be higher as the patient possessed two risk factors,(female gender and a repeat procedure). Transoesophagealechocardiography was recommended by the cardiologists forthe initial procedure but was refused by the patient. Currentlythere are no guidelines on the use of TOE to aid trans-septalpuncture during pulmonary vein isolation. Transthoracicechocardiography was used to diagnose a pericardial effusionbut a detailed examination was not performed due to thepatient’s cardiovascular instability. Perforation of the aorticvalve and the presence of the fistula following removal of theBaird sheath were diagnosed using transoesophagealechocardiography in the operating theatre. This casedemonstrates the usefulness of TOE to assist trans-septalpuncture during difficult cases of pulmonary vein isolation, toaid the surgical management of complications, and theimportance of on-site cardiothoracic anaesthetic and surgicalexpertise.

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, HartRG. Prevalence, age, distribution, and gender of patientswith atrial fibrillation. Analysis and implications. ArchIntern 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 thecatheter ablation of atrial fibrillation – incidence andmanagement. Circulation 2009; 73: 221-226.

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

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

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

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


PA G E 19

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PA G E 22

4) Multiple cardiac papillaryfibroelastomas in associationwith rheumatic heart diseaseA 49yr old woman presented with breathlessness and legoedema. The shortness of breath had been slowly progressiveover the previous three years. Past medical history was largelyunremarkable and in particular there was no history ofrheumatic fever. She had presented with breathlessness andhaemoptysis during a pregnancy eleven years earlier butinvestigations revealed no evidence of pulmonary embolism.

Clinical examination revealed decompensated biventricularfailure and rapid atrial fibrillation. She had finger clubbing buthad been known to have “rounded” finger nails even in her 20s.Cardiac auscultation revealed a murmur of mitral regurgitationat the apex. She had tender hepatomegaly.

A subsequent bedside TTE showed severe, rheuamtic mixedmitral valve disease with mild tricuspid regurgitation andmoderate pulmonary hypertension. On further review, the TTEalso showed an unusual appearance of the aortic valve with asmall mobile mass attached to the ventricular side of the non-

coronary cusp (NCC) and a further spherical mass was seen justabove the left coronary cusp (LCC). There were ill definedmobile shadows on the mitral valve and a further spherical massattached to the lateral wall of the LV near the apex. (Figure 1).

A transoesophageal echocardiogram confirmed severerheumatic mitral valve disease with multiple masses on theventricular side of the mitral valve and two spherical masses onthe NCC and LCC of the aortic valve.(Figures 2-3) A furthermass was evident in the LV near the apex.

In view of her progressive breathlessness, finger clubbing andpulmonary hypertension, a respiratory opinion was sought and aCT scan of her thorax organised. This revealed mediastinallymphadenopathy of up to 4cm. A diagnosis of possiblelymphoma was raised but later refuted after a negativetransoesophageal mediastinal lymph node biopsy showingreactive lymphadenopathy.

Cardiac surgery was performed successfully with mechanicalaortic and mitral valve replacements. At surgery she was foundto have multiple gelatinous masses which were all excised.Subsequent histology revealed these masses to be typicalpapillary fibroelastomas (CPF). (Figures 4-5).

The post operative course was uneventful and her exercisetolerance has improved to levels which she had not experiencedfor five years or more.

Discussion:

CPFs are usually found to be small pedunculated masses onshort stalks. They commonly measure around 1cm but can beas large as 4cm.2 On gross inspection they are likened to a seaanemone due to numerous and delicate fronds. (Figure 5) CPFshave 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 tothe endocardium.4 On atrioventricular valves they are mostoften found on the atrial surface and on semi lunar valves theycan be found on either side.5 There is no male or femalepredominance and the tumours have been found in patients asyoung as a 6 day old neonate and in a 92yr old although theyare most commonly found after the 5th decade.1

Although up to 50% of patients with CPFs are asymptomaticand the tumours are histologically benign, they are associatedwith serious clinical consequences due to embolisation. It isthought that rather than tumour material embolising, the tumoursurface acts as a nidus for platelet and fibrin deposition whichthen has the potential to embolise.6 If the tumours are left sided,neurological complications including stroke are frequent.7 Otherembolic complications include myocardial infarction8,9 , retinalartery embolism10, pulmonary embolism11 and sudden death.12

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

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

Fig. 3. 2CPFs attached to the aortic valve -TOE LAX view.


PA G E 23

Due to their embolic potential, the consensus is that evenasymptomatic individuals should be considered for surgery andmost clinicians advocate anticoagulation. Surgical excision iscurative and no case of CPF recurrance has been reported.

The case described above is unusual in having multiplepapillary fibroelastomas on 3 different sites within the heart andthe very rare association of rheumatic disease and CPFs whichto our knowledge has only been reported once before.13

This case also demonstrates the usefullness of bothtransthoracic and transoesophageal echocardiography inassessing intracardiac tumours. With modern ultrasoundmachines the precise location and size of intracardiac massescan be defined along with their site of attachment and theirrelationship to surrounding structures.

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

Conclusion:

Cardiac papillary fibroelastomas are rare primary tumours of theheart. Although histologically benign, they can cause seriousembolic complications. They are most commonly foundincidentally by TTE or TOE. Surgical excision even inasymptomatic individuals is advised due to their potential forembolic complications.

L Bhalla, R Wheeler, Mr. Peter O’Keefe

University Hospital of Wales

References:

1.Shahian DM, Labib SB, Chang G. Cardiac papillaryfibroelastoma. Ann Thorac Surg 1995;59:538-41.

2.Abu Nassar SG, Parker JC Jr. Incidental papillary endocardialtumour. Its potential significance. Arch Pathol 1971;92:370–6

3.Ryan PE Jr, Obeid AL, Parker FB Jr. Primary cardiac valvetumors. J Heart Valve Dis 1995;4:222-6.

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 Surgery1999;117:106-10.

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

6.Mc Fadden PM, Lacy JR. Intracardiac papillaryfibroelastoma: 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 coronaryostial obstruction due to papillary fibroelastoma leading tomyocardial ischaemia and infarction. Am J Cardiol1991;67:104–5.

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

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

11.Waltenberger J, Thelin S. Images in cardiovascularmedicine. Papillary fibroelastoma as an unusual source ofrepeated pulmonary embolism. Circulation 1994;89:2433.

12.Amr SS, Abu Al Ragheb SY. Sudden unexpected death dueto papillary fibroma of the aortic valve. Report of a case andreview of the literature. Am J Forens Med Pathol1991;12:143–8.

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

14.Sun JP, Asher CR, Yang XS, Cheng GG, Scalia GM,Massed AG, et al. Clinical and echocardiographiccharacteristics of papillary fibroelastomas: a retrospectiveand prospective study in 162 patients. Circulation2001;103:2687-93.

15.Minatoya K, Okabayashi H, yokota T, et al. Cardiacpapillary fibroelastoma; rational for excision. Ann ThoracSurg 1996;62:1519–21.

Fig. 4. Excised aortic valve with attached CPFs.

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


PA G E 24

5) Caution Required

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

6) “Fluid around the heart” –is it always pericardial orpleural? A 72 year old man had a transthoracic echocardiogramperformed as part of an investigation into a recent episode ofchest pain. He was known to have severe liver disease althoughthis was not recorded on his in patient request form.

Parasternal and apical views were relatively unremarkable butthe subcostal view surprisingly showed a large echo free areaadjacent to the anterior border of the right ventricle. In additionthere was a thin strand of “tissue” running across this presumedcollection of fluid and it appeared to oscillate (Figures 1 and 2).

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

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

Analysis of the previous parasternal and apical views revealedno pericardial or pleural effusions and transmitral pulsed wavedoppler showed no respiratory variation. The sonographerrequested a medical opinion within the cardiac department andthe patient’s hospital notes were reviewed. This confirmed thepatient had severe liver disease and had significant ascitesclinically and on a recent abdominal ultrasound. In addition achest x-ray performed on the same day was carefully inspectedand confirmed the absence of any pleural effusions.

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

the IVC to be clear. This image highlights the fact that a

definitive diagnosis should not be attempted from

echocardiographic images alone.

1 week on

Paul Russhard, Deepa Sureshkumar,

Basildon Hospital, Essex


PA G E 25

Discussion

There is little published on the transthoracic echocardiographicimages of ascites and consequently the finding of an echofreearea around the heart that does not fit with either pericardial orpleural fluid may cause confusion for the sonographer.

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

In this study they purposefully performed transthoracicechocardiography on 32 patients with ascites. On the subcostalview in each case they found that a strand of tissue (thefalciform ligament) that bisected the translucent space betweenthe right border of the heart and the liver was always present.They concluded that the presence of the falciform ligament inthis echolucent space confirms ascites.

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

The falciform ligament is a fold of peritoneum that is firmlyattached to the liver and reflects back on to the posteriorabdominal wall and then on to the inferior surface of thediaphragm (Figure 3).

It only becomes apparent on TTE when there is a significantamount of fluid on either side of this structure as occurs inascites or with a large intra-peritoneal bleed. The authors of thisstudy also noted that the falciform ligament made characteristicwave-like motions within the space and presumed that this wasdue to indirect transmission of the cardiac motion to theligament.

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

This case report confirms this very useful echocardiographicfinding but we would advise sonographers to confirm thatascites is present in these patients before concluding that anecholucent space around the heart is in fact due to ascites. Thismay be confirmed by simply reviewing the notes or looking upother radiological tests such as abdominal ultrasound or CT.

References

1.Cardello FP, Dong-Hi AY et al. The falciform ligament in theechocardiographic diagnosis of ascites. Journal of theAmerican Society of Echocardiography 2006; 19(8):1074.e3-1074.e4

Acknowledgements: We would like to acknowledge that thepost mortem image was kindly provided by Dr Mark Deverell,Pathologist, Poole Hospital

GLA Cumberbatch, Jodie Taplin, Poole Hospital

BSE COUNCIL NOMINATIONSThe BSE Council comprises 10 elected members (who are automatically Trustees of the Charity and Directors ofthe 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 anadditional year as ‘Immediate Past-President’. The elected members can co-opt additional members who eachserve for a one-year term. This year there are three vacancies for elected Council members to serve from 2010-2013. 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 electionand to vote once the elections open.

Anyone wishing to nominate a candidate should to so in writing via email to: [email protected]. Email isthe 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 candidatethat s/he is willing to stand for election, plus a statement of a maximum of 150 words in support of his/herapplication.

Any BSE member can serve on the Council. It is very important that the Council reflects the membership as awhole, both professionally and geographically. If you would like to learn more about what is involved beforedeciding whether to stand for election please contact the President at [email protected] or the HonSecretary at [email protected]


PA G E 26

3D SPECKLE TRACKING – A NEWERA FOR ECHOCARDIOGRAPHYAND MYOCARDIAL IMAGING?What is Speckle Tracking?Tissue Doppler imaging (TDI) was the first technique used toassess regional wall deformation, strain and strain rate.However, this method suffered mainly from being angle-dependent (due to the use of Doppler) 1. Two-dimensionalspeckle-tracking echocardiography (2D-STE) was introduced inorder to solve this issue. 2D-STE analyzes wall motion byfollowing acoustic markers on gray-scale images andintegrating frame-to-frame changes but is limited by its two-dimensional (2D) nature 2. Speckles are tracked in 2D planesand therefore only a portion of motion is detected since specklesmove in three dimensions.

Concept of 3D Speckle TrackingRecently, the concept of speckle tracking in three dimensionshas been applied, permitting assessment of real movement andtrue three-dimensional (3D) strain analysis. 3D-STE uses thepattern-matching technology in real 3D motion vectors withinthe acquired 3D volume. The use of 3D-STE for left ventricular(LV) volume quantification and for regional strain measurementhas been validated against cardiac magnetic resonance (CMR)and sonomicrometry 3,4,5. Other studies evaluated 3D-STE incomparison to 2D-STE and reported that 3D-STE is less time-consuming, enabling the analysis of a greater number ofsegments 6, 7. Tanaka et al reported that 3D-STE couldsuccessfully quantify 3-D dyssynchrony and the site of latestmechanical activation 8. Currently, the use of 3D-STE isexpanding taking advantage of its unique ability to assess andquantify reliably and in three dimensions any deformationabnormality before it becomes visually recognisable(asymptomatic patients with normal systolic function andischemia or severe valvular disease) and to guide clinicaldecisions on further treatment (early identification ofchemotherapy-induced cardiomyopathy).

Practicalities of 3D Speckle TrackingStandard acquisition is rapid as only a single apical full volumedata set acquired from four consecutive cardiac cycles duringbreath hold is required for subsequent off line analysis.Endocardial and epicardial contours are traced and the dedicatedsoftware (Toshiba Artida, Toshiba, Tokyo, Japan) tracks thecontours in subsequent frames to calculate strain parameters(radial, longitudinal and circumferential strain, apical and basalrotation and torsion) in all sixteen LV wall segments within afew seconds. Frame by frame wall motion parameters are colourcoded and can also be displayed as a dyssynchrony imagingmap.

Research applications of 3D Speckle Tracking3D-STE is currently being applied in a range of research studieswithin the Oxford Cardiovascular Clinical Research Facilitybecause of its ability to provide rapid 3D assessment ofmyocardial strain. Changes in myocardial function may be ofkey importance in the early development of the cardiovasculardysfunction that precedes many clinical conditions. 3D STEtherefore offers an opportunity to identify factors that influencedisease development, monitor progression and assess responseto preventative treatment. There are particular focuses on themyocardial dysfunction associated with valve disease,hypertension and ischaemia with several large scale studies andclinical trials in progress.

Conclusion

3D-STE has emerged as a rapid and simple tool to collectinformation on myocardial function in both the clinical andresearch setting. Ongoing work has the potential to identify newclinical applications of 3D-STE as well as use 3D-STE as ameans to understand biological changes in myocardial function

from early in the development of a range of cardiovasculardiseases.

Christos Basagiannis, Paul LeesonJohn Radcliffe Hospital, Oxford

References

1.Marwick TH. Measurement of strain and strain rate byechocardiography: Ready for prime time? J Am Coll Cardiol2006, Apr 4; 47(7): 1313-27.

2.Pérez de Isla L, Vivas D, Zamorano J. Three-Dimensionalspeckle tracking. Current Cardiovascular Imaging Reports2008; 1(1): 25-9.

3.Maffessanti F, Nesser HJ, Weinert L, Steringer-MascherbauerR, Niel J, Gorissen W, et al. Quantitative evaluation ofregional left ventricular function using three-dimensionalspeckle tracking echocardiography in patients with andwithout heart disease. Am J Cardiol 2009, Dec15;104(12):1755-62.

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

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

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

7.Saito K, Okura H, Watanabe N, Hayashida A, Obase K, ImaiK, et al. Comprehensive evaluation of left ventricular strainusing speckle tracking echocardiography in normal adults:Comparison of three-dimensional and two-dimensionalapproaches. J Am Soc Echocardiogr 2009, Sep; 22(9): 1025-30

8.Tanaka H, Hara H, Saba S, Gorcsan J 3rd. Usefulness ofthree-dimensional speckle tracking strain to quantifydyssynchrony and the site of latest mechanical activation.Am J Cardiol, 2010 Jan 15; 105(2): 235-42.

Installation of Toshiba Artida in the Oxford CardiovascularClinical Research Facility (CCRF), located within the JohnRadcliffe Hospital. CCRF provides a dedicated, staffed clinicalresearch environment, with particular expertise inechocardiography, vascular assessment and clinicalphysiology.

(Left to right) Dr. Merzaka Lazdan, Dr. Paul Leeson, MairHowe and Helen Deacon Toshiba Medical Systems, MsArancha della Horra and Dr. Saul Myerson.


PA G E 27

Across2. 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)

ECHO CRYPTIC CROSSWORD

Down1. 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)

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

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 28

LETTERS TO THE EDITOR1) Response to BSE Guidelines: Mitral Valve Repair(published June 2010)

Dear Education Committee

I read the recently published BSE guidelines on 2-dimensionaltransthoracic assessment of the mitral valve with great interestand thank the education committee for this comprehensive andvery helpful publication. I wish to raise two points forconsideration.

Firstly, the section on leaflet motion (in the PLAX view)describes Carpentier type 3a as leaflet restriction in systolealone and type 3b as restriction in both systole and diastole.However, the original Carpentier classification system describedtype 3a as restriction in systole & diastole (e.g. rheumatic mitraldisease) and type 3b as restriction in systole alone (e.g. chronicischaemic MR). The 2006 American (ACC/AHA) guidelines onmanagement of valvular heart disease similarly describerestriction in systole and diastole (type 3a) or systole alone(type 3b), respectively.

Secondly, the apical 2 chamber view (AP2C) is described asshowing the scallops A1/A2/(A3) and P3. However, again, thisappears to be in contrast to several other texts. The AP2C view- sometimes called the inter-commissural view – is usually saidto 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 handbookof echocardiography, ESC textbook of cardiovascular medicineand the education section of the European association ofechocardiography (EAE) website all also state that P1-A2-P3are, generally speaking, the scallops seen in the A2PC view.The latter two aforementioned sources cite a JACC paper byMonin et al in 2005 as their reference (also used in the BSEguidelines).

I would thus be most grateful if the Education committee couldclarify 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 assessmentof the mitral valve with a view to repair from the BritishSociety 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 themanagement of patients with valvular heart disease. Circulation(2006); 114, e84-e231

Monin J-L, Dehant P et al. Functional Assessment of MitralRegurgitation by Transthoracic Echocardiography UsingStandardized Imaging Planes. J Am Coll Cardiol (2005); 46;302-09

Reply from the Education Committee

Dear Dr Shah

The Education Committee are grateful for your kind commentsand feedback in relation to the recently published GuidelineProtocol for the Assessment of the Mitral Valve with a View toRepair. You raised two points.

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

Secondly, the paper by Monin used as a reference does describethe transthoracic apical two chamber view as demonstrating aninter-commissural image of the mitral valve, with the P1 scallopon the left (adjacent to the aorta), the P3 scallop on the right(adjacent to the atrial appendage) and the A2 scallop inbetween. This has been slavishly copied without discussion intoThe Oxford Specialist Handbook of Echocardiography, TheESC Textbook of Cardiovascular Medicine and the educationsection of the European Association of Echocardiography(EAE) website.

The Education Committee take the practical view that thescallops which can be seen from this acoustic window dependon the orientation of the heart and the degree of rotation of theprobe. With minor changes in orientation of the heart androtation of the mitral valve, two images can be produced –either the P3-A123, as shown in our document, or P3/A2/P1shown below. There is very little movement required betweenthese two, and we have added this into our dataset to explainthis more fully.

Bushra Rana and Rick Steeds


PA G E 29

2) Are the NICE Guidelines really nasty?!

My, what hostility the new NICE guidance for the diagnosis ofangina has caused; I have yet to find anybody ready to speak upfor them. Undoubtedly this is one of the rawest, least polisheddocuments that NICE has produces. It feels somehowunfinished, and as if a couple of further rewrites might havebeen of benefit. The recommendations on acute chest pain havesome eccentricities but revolve around the appropriate use ofECG and biomarkers. I will not address this section but ratherexamine the sentiment that lies behind non acute section of thedocument. The guidelines are aimed quite specifically at thediagnosis of angina - not at the prognostication in people withcoronary heart disease, not at directing management in coronaryheart disease: simply, has this person with the symptom of chestpain 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 PainClinic is a bit rubbish. There is no doubt the exercise test istremendously useful in selected cases, but this strategy has torun across the country in clinics, often nurse led, that are packedwith people who can’t exercise, or have bundle branch blocks,or are women, or have LVH, or are non- caucasian, or havesingle vessel disease, or are at low risk, or are at high risk, orare sweaty, or are unusually hairy.

The NICE guidance offers several advantages. Firstly it re-introduces clinical judgment. If the chest pain sufferer haseffectively no risk of coronary disease, do not do a test. For toolong rapid access clinics have tested first and only then talked.The performance of all non invasive ischaemia detecting tests ispoor when risk is low. In this population a positive exercise testor even stress echo is quite likely to be a false positive test.Anatomical tests, in the form of cardiac CT have something tooffer both by ruling out anatomical issues, but also in flaggingup the presence of atherosclerosis through a raised coronarycalcium. There are however two problems with the CTrecommendation; the presence of non-calcified vulnerable softplaque in young people causes everyone anxiety although thefrequency in patients presenting with chest pain is likely to below; the other is roll out. But surely there is nothing wrong withletting a guideline express a legitimate ambition that incentiveshospitals to achieve it.

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

Where do these guidelines leave the echo lab? Firstly they donot undermine the pivotal role of echo in defining cardiacprognosis and management strategy through the assessment ofglobal function and wall motion abnormalities. It is a hearts andminds initiative that is required to get the LV cineangiogrambanished, with the magic lantern, to the dustbin of diagnostichistory. Everyone going to the cath lab should have an echo, butthis does not necessarily influence the diagnosis or angina.Stress echo is such a valuable recourse and performs with ahigh level of sensitivity and specificity. This deteriorates as thechance of disease goes down and as the prevalence of single orno vessel disease goes up. Applied in the wrong population thenstress echo could lose its reputation for reliability (somethingthat has bedevilled myocardial perfusion scanning).

Reserving stress echo for cases in which it is likely to performat high accuracy is a sensible strategy. Likewise theseguidelines do not change the huge role of stress echo in defininga management strategy in patients after the cath lab.

This is an imperfect guidance certainly, and should in no waybeen seen as a blueprint for the total management of coronaryartery disease. On the other hand as a practical strategy todecide whether someone pitching up with chest pain hasblocked arteries it works rather well. It relegate forever theexercise test which is not suited to being a mass triage tool andrequires considerable expertise to properly request. It re-instatesthe concept that where likelihood is effectively zero no testshould be performed, steering us away from the Americanmodel that it is better to test someone than to talk to them.

Most importantly it incentives hospitals to make the necessaryinvestment in advanced cardiac imaging, both in the form of acardiac CT and a stress echo service, something they havehistorically failed to do.

Guy Lloyd, East Sussex NHS Trust

ARE YOUR DETAILS UP TO DATE?Please don’t forget to let us know if you are changingyour home address, place of work or e-mail so that wecan easily contact you if we need to. This is especially

important if you are currently working towards BSEAccreditation. Changes to details can be e-mailed to

[email protected]

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


PA G E 30

3) A further response to the NICE guidelines.

I read with interest your interpretation of the recent NICEguideline on chest pain diagnosis and your concern about theimpact on echo services (ECHO Issue 70, June 2010). In myexperience, (admittedly only 22 years rather than your 40) arapid diagnosis of an acute coronary syndrome (ACS) is bestmade with an ECG rather than an echo. However, in patientswith normal ECG, but suspected ACS, echo is advocated toassess for regional wall motion abnormalities. While I supportparamedic assessment of patients with chest pain by recordingand interpreting ECGs, it may be cumbersome and timeconsuming for them to perform echocardiography beforedeciding whether a patients needs to be admitted to hospital! Inmy opinion, the acute chest pain guideline gives clinicians clearpathways to diagnose and manage patients with suspected ACSincluding, where indicated, the use of echo.

In patients presenting with stable chest pain, the clinicalassessment alone, not just history, may be sufficient to make adiagnosis of angina without the need for further diagnosticinvestigation. The management of angina patients is not coveredin this guideline and will be addressed by NICE when theypublish the stable angina guidelines in 2011. With regard toinvestigation of patients with ‘atypical’ chest pains, theestimation of the likelihood of coronary artery disease (CAD) isbased on sound research evidence1. This is not an arbitrarypercentage chance but a unique individual figure if calculatedusing the model suggested by Pryor et al1. CT calcium scoringis a quick, safe and accurate method of identifying coronaryplaques and is advised in patients with low to moderatelikelihood of CAD. In patients with a higher (30-60%)likelihood of CAD, functional testing is recommended,including stress echocardiography if preferred. Anyone with ahigher likelihood should be offered diagnostic coronaryangiography. It has now been widely demonstrated that theexercise tolerance test is limited in the diagnosis of chest painand does not add prognostic value to that obtained from clinical

assessment2. This clear and systematic approach toinvestigating 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 transthoracicechocardiography in the diagnosis of chest pain.

Advances in health care are vital and rarely come cheaply. Theyrequire us to challenge traditional thinking and embrace newtechnologies. We should never continue doing what we alwaysdid just because it is easier or seems right, when research tellsus differently. The improved management of CAD now meansthat patients are surviving acute events in greater numbers andliving longer. In asking the question “Will your Echo Service beable to cope?” the real challenge is the management of longterm chronic heart disease where, you’ll be pleased to hear, Ithink 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 theHistory and Physical in Identifying Patients at Increased Riskfor Coronary Artery Disease

Annals of Internal Medicine;118: 81-90

Sekhri N, Feder GS, Junghans C, et al. (2008) Incrementalprognostic value of the exercise electrocardiogram in the initialassessment of patients with suspected angina: cohort studyBritish Medical Journal; 337:a2240

Cooper A, Calvert N, Skinner J, et al. (2010) Chest pain ofrecent onset: Assessment and diagnosis of recent onset chestpain or discomfort of suspected cardiac origin. NationalInstitute for Health and Clinical Excellence Guideline CG95

IMEDIX SIMULATORSWe are delighted to announce that Vimedix (CAE Healthcare) willbe 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 followingthe 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. Abuffet and drinks will be available to all attendees.


PA G E 31

BSE ACCREDITATION UPDATESTransthoracic 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 befound, 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 beexpected to use the revised version. However candidates who have previously taken the examination and are due to submitlogbooks by end December 2010 will have the option to use either the new or previous version. We do ask however, that candidatesclearly 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 beno initial charge to candidates who decide to sit this pilot exam, but candidates who pass the exam can then choose to pay the usualexam fee (£150) 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:[email protected].

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 normaland one should show an example of aortic stenosis. Image acquisition, optimization and interpretation will be assessed. It isimportant that all reports and digital images are completely anonomysed (removal of all patient identifier data like name, date ofbirth, address and hospital or NHS number).

The BSE Education Committee recently produced guidelines on performing a comprehensive TOE examination. It is recognised thatit may not be possible to acquire all the recommended views in all patients. In particular, there are certain probe positions that maybe 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 thisfacility becomes available. Reports should include quantitative measurements, observations, summary and conclusion. An exampleof the marking schedule for the digital studies will be included in the new accreditation documents and can be downloaded fromwww.bsecho.org/accreditation.

Henry Skinner

Accreditation Committee

COMMUNICATING WITH THE SOCIETYFFoorr ggeenneerraall eennqquuiirriieess ccoonncceerrnniinngg mmeemmbbeerrsshhiipp ssuubbssccrriippttiioonnss,, mmeeeettiinnggss,, eettcc..::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: [email protected] Web: www.bsecho.org

FFoorr qquueerriieess rreeggaarrddiinngg AAccccrreeddiittaattiioonn::

BSE Accreditation Administrator

Executive Business Support Limited, City Wharf, Davidson Road, Lichfield, Staffordshire WS14 9DZ

Tel: 0845 094 4728 Fax: 0121 355 2420 Email: [email protected] Web: www.bsecho.org

BSE President: Dr Navroz Masani

c/o BSE Administrator (Docklands address) Email: [email protected]

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: [email protected]


PA G E 32

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

In preparation, for the twelve months leading up to my appointment there had been several changes made, including the changing ofthe accounting year so that it now runs from April 1st to 31st March each year in line with the BSE Membership year. The accountspresented at the 2009 AGM reflected a 9 month period to be compared to those being prepared, as we speak, that will contain a full12 months. The figures tabled below are taken from reports produced from the new accountancy package, SAGE. This wasintroduced to replace the original accountancy database as it is a recognised commercial product with training days and supportprovided. This system had been running alongside the original system and went ‘live’ in April 2009. Direct comparison of incomeand expenditure reports is also made more difficult this year due to the different categories and sub-categories now available on thenew system.

Our new Accountants, Phillips Kobbs and Co Ltd., are based locally to the BSE offices and have provided on-site support andadvice 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 bebeneficial. This system has been running for approximately six months in an attempt to reduce banking costs and speed up paymentof 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 withthe new details. Members who pay by Direct debit will not be affected. Once the new bank account has been finalised, the Societywill re-consider their Reserves Policy together with their Bank Manager and Accountant, following amendments to the guidelinespublished by The Charities Commission.

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

The Annual meeting was held in Liverpool over three days with the exams, Core Training and FEEL being held on the Thursdayfollowed by the usual two day scientific meeting. Our social event held on the Friday evening at Circo Bar was a great success. Thefull 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 additionalDepartmental 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 £2087.98

Website/Newsletter £16759.50 Accreditation £75,743.47

Other income £358.51 Travel £1774.57

Printing and Stationery £73,586.67

Professional Fees £1011.49

Equipment Hire and Rental £1538.77

Bank Charges £2927.54

Subscriptions £1023.65

Total Income £468,947.49 Total Expenditure £388,672.50

Surplus £80,274.99

COMMITTEE REPORTS


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Education Committee ReportThis year has been a busy and productive one for the EducationCommittee. The year started with the largest Annual GeneralMeeting ever held by the British Society of Echocardiography,with over 750 delegates attending the new conference centre inLiverpool at the beginning of October. Before the main meetingopened, a ‘Core’ training day was held for those starting out inechocardiography, with a second training opportunity runconcurrently for those wishing to use peri-arrestechocardiography. The main meeting focussed on ‘Medicineand the Heart’ and opened with a popular ‘How to…’ sessionrun solely by sonographers with the aim of the practisingechocardiographer in mind. The lectures were supported by‘Hands-on’ sessions run by applications specialists from themajor echocardiography companies, focussing on 3Dassessment of the left ventricle and mitral valve. These will berun again this year and have been popular, so book early! TheAnnual General Meeting is returning to Bournemouth this year,where for the first time there will be parallel sessionsthroughout both days, enabling participants to choose between‘simple’ and ‘advanced’ topics. Other new developments will beautomated feedback and the availability of some sessions as podcasts.

The educational programme continued in March with a verysuccessful Advanced ImagingTraining day, held at the RoyalSociety of Medicine. This focussed on pre-operative, peri-operative and post-operative imaging in the management ofpatent foramen ovale and mitral regurgitation. The AdvancedImaging Training day will be run at the same venue in Marchnext year, and brings best practice in echocardiography to abroad audience of sonographers and cardiologists.

The BSE had a prominent place at the British CardiovascularSociety this year, running three full sessions on myocardialmechanics, the failing right heart and repair of the mitral valve.The feedback from these sessions was very positive and theBSE hope to continue to have influence through thedevelopment of a new Imaging Council run by our PastPresident Simon Ray.

The Education Committee has been busy on the writing front aswell, with a full protocol published for the performance oftransoesophageal echocardiography and a new version of theminimum dataset on transthoracic echocardiography inpreparation. Supplementary protocols have been published onhypertrophic cardiomyopathy, Marfans syndrome, and mitralregurgitation. The next to be published will cover pulmonaryhypertension, and protocols in preparation include assessmentof mitral stenosis for percutaneous commissurotomy, aorticstenosis, and diastolic function. Work is also carrying on in thedevelopment of guidelines for probe cleaning and peri-procedural sedation.

December 2009 saw the publication of the BSE Supplement inthe European Journal of Echocardiography onCardiomyopathies, with a further supplement to be publishedthe same time this year on interventions relating to patentforamen ovale and mitral regurgitation. Please let us know ifthere are other things that you are keen for us to develop andsign up for Bournemouth!

Communications Committee ReportCommunication is a two way street, and the street is currentlybeing repainted. The only function of the BSE is to promotethe interests of its members whether through politicalrepresentation, guideline and policy devolvement or byeducational materials and events. As part of creating a modernsociety, a process has been launched to dramatically increasethe amount, extent, and quality of information and directengagement with the membership.

What does this actually mean?

A new website is currently being planned. The old sitecontains a wealth of useful material but is of a design that isnow obsolete. The new site will have a much greater diversityin linking to an on line educational hub. Embedding thealready 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 learningmodules and an area of debate and chat which will take overfrom the current forum.

The objective is to make the website the ‘must see’ on linefacility for all echocardiographers in the UK.

But communication is about more than just websites. TheEcho journal is already a fantastic facility - although short ofwilling authors! And there are other aspects including sitevisits, problem solving, local educational meetings andengagement which must all be part of the process.

Yes that is a call for volunteers!

We recently established a new team for the CommunicationsCommittee, however with a growing remit we would welcomeadditional members. If anybody would like to becomeinvolved with this process, then their contribution would behugely welcomed. Areas people might like to think about are:

Techies - who are good with IT and can help improve thequality 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 firstFacebook 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 34

2009 AGM MINUTESUnconfirmed minutes of the Annual General Meeting of the British Societyof Echocardiography Limited

Held on Friday 2nd October 2009, 14.30BT Conference Centre, LiverpoolPresent: 95 members attended the meeting

1. Apologies: None

2. Minutes of the 2008 AGM There were no corrections to the minutes. Proposed: Dr Kevin FoxSeconded: Gill WhartonPassed nem con

3. Matters arisingThere were no matters arising

4. Notification of deathsNone known at the time of meeting

5. Secretaries report – Jane AllenThe results of the elections to council were announced. The following wereelected 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 notbeen successful on this occasion.Number of current members 2425

6. Changes to BSE constitutionIn 2002 BSE changed to a Limited Company. In 2008 it was recently beendiscovered that the process had not been fully completed and members wereunable to vote on the proposed changes last year.The lawyers have now completed the necessary paper work and this has beensent to every BSE member by post.

Vote to accept new changesProposed: Dr Rick Steeds, Seconded: Dr Mark MonaghanPassed nem con

7. Treasurers report – Graham LeechDraft 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 moremembers sit the examinations; however, the administration costs of EBScontinue to rise.In the past BSE has gained interest from money in the bank but at present wheninterest rates are very low the society may have to consider others methods ofinvestment.The ECHO supplement runs at a loss but the society sees this as an acceptedservice 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 werehigh, 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 theAGM was ~3:1 of members declare BSE fees on their tax returns

8. Motion to re appointIt was proposed to appoint a new accountant – Philips, Kobbs and CoProposed: Nav MasaniSeconded: Dr Guy LloydVote: 2 against, 93 for.

9. Questions from the floor in regard to the published committee reportsCommittee reports published in September edition of ECHOAccreditation committee – Chair: Dr Ranjit MoreCommunication committee – Chair: Jane GrahamECHO – Editor: Dr Gordon WilliamsEducation Committee – Chair: Dr Rick SteedsFinancial Report – Graham LeechNo questions were raised

10 Any other businessThanks were given to Graham Leech who is standing down as HonoraryTreasurer. Tracy Ryan will take up the post of Treasurer from this meeting.BSE acknowledged the huge amount of work and time that Graham had givento the society since it began in 1990. No other one individual and done moreover the period of time.BSE thanks Harry Hindle, Dawn and Ingrid for all their hard work in makingthe annual conference another huge success.The winner of the best Scientific Abstract 2009 was announced as Dr McIntosh,Eastbourne Hospital.

11. Presidents Report – Simon RayBSE has been involved with many projects over the last 12 monthsAccreditation: The TTE and TOE processes have been updated and the newsyllabi are now complete and will be available on the website after the meeting.The European Association of Echocardiography has introduced paediatricaccreditation and BSE members, who in the past have held paediatricaccreditation, will be able to apply for re accreditation. BSE will be contactingthese members shortly.BSE has worked closely with the ICU society with regards to the FEELaccreditation process.Departmental Accreditation is led by Helen Rimington. The British HeartFoundation have offered a grant of £50,000 to get a web based applicationlaunched. It is suggested that departments would be able to perform QualityAssurance online in the future.IT – BSE has invested money in redesigning its IT. This will improvecommunication between the society and its members. The society has alsobought new PC’s for the administration office.

12. New Presidents Address – Nav MasaniThanks were given to Simon Ray for the huge energy he has given to thesociety over the last 2 years. He has completed the transition from a keen andactive society into a professional organisation that is now well respected byvarious bodies including the Department of Health and the British HeartFoundation.BSE is a leader in the field in accreditation; this is now embedded in ourpractice. Other organisations are now taking this on but BSE is well ahead ofthe game and already has processes in place for reaccreditation in both TTE anddepartmental accreditation.The vision for the next 2 years is to continue to work with the Department ofHealth on MSC (Modernisation of Scientific Careers).Training continues to be an important role of BSE and this will continuedrawing on the experiences of previous past presidents and through the counciland committees.The BSE is keen to attract new blood to its committees and welcomes anyonewho is interested.BSE wants to improve communication with its members and work will continueto improve the website.Simon Ray closed the AGM at 15.10.


PA G E 35

2010 ANNUAL GENERAL MEETINGAGENDA

Notice is hereby given that the Annual General Meeting of the British Society of Echocardiography, aCompany Limited by Guarantee, will be at 14.30 – 15.00 on Friday 29th October 2010 at the BournemouthInternational Centre.

Any member of the Society, in good standing, whether or not attending the meeting is entitled to attend andvote at the AGM.

The agenda will be as follows:

1. Apologies for absence2. To receive the Minutes of the 2009 AGM and approve them3. Matters arising from the 2009 AGM minutes not dealt with elsewhere4. Notification of Deaths5. Society activities

Workforce development

Links with other societies

• MSC

• Paediatric Re-accreditation

6. Honorary Secretary’s ReportElection of new council members

Membership summary

7. Motion to make changes to the constitution8. 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-appointCompany Auditor/ Independent Financial Examiner

Bank of Scotland as Bankers

Company Lawyers

10. Questions from the floor in regard to published committee reportsAccreditation Committee

Communications Committee

Education Committee

Financial Report

10. Any other businessMembers 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 36

COURSES DIRECTORY 2010/11Details of courses/meeting for the 2010/10 academic year areavailable online via www.bsecho.org

There are two quick and easy routes to finding a suitablecourse, each accessible from the home page.

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

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

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

If you wish to include an upcoming course in the onlinedirectory please contact Dawn Appleby on 020 7345 5185 [email protected]. All echo related courses are welcomed.

Cardiac Physiologist – Australia

Company Background - Perth Cardiovascular Institute is one ofWestern Australia’s largest private cardiology service, which providescomprehensive cardiovascular assessments, treatments and interven-tion services to clients.

The Role - Reporting to the Senior Cardiac Physiologist, this fulltimerole is responsible for maintaining the PCI image of a premier cardio-vascular 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 inCardiac Physiology. The ability to obtain accreditation and member-ship with the Australasian Sonographer Accreditation Registry (ASAR) isessential. Experience in adult transthoracic, stress and transoe-sophageal echocardiography will be well regarded.

Salary will be negotiable and experience based. Reasonable reloca-tion and visa assistance shall beprovided to the successful candidate.

*To be successful, the candidate will be required to provide evidenceof claimed qualifications or experience.*How to Apply - An application containing a cover letter, a resume andreferee details should be submitted by the 15th October 2010 [email protected].

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


PA G E 37

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

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

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


PA G E 38

Imaging myocardial mechanics:TDI, speckle and 4D6th annual Course

9 - 10 November 2010Moat 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: [email protected]

Tel: (01782) 553550

We are grateful to GE Healthcare for their support of this course

Echo in Acute Care -The FATE protocol

A “hands-on” course aimed at non-cardiologists

Topics include LV function assessment, valvular disease and

effusions

Presented by two consultant echocardiologists

Supported by GE Healthcare

Moat House Hotel, Stoke-on-Trent12-13 February 2011

Full Details : [email protected]

01782 553550

High quality echo educational courses from

University Hospital of North Staffordshire

Imaging Myocardial Mechanics:

Tissue Doppler, Speckle and 4D

Sixth Annual Meeting

A “hands-on” course:

• Basic principles

• Deformation imaging

• Dyssynchrony imaging

• Practical image acquisition

• Dataset interrogation

Moat House Hotel, Stoke-on-Trent

9 - 10 November 2010

Full Details : [email protected]

01782 553550

High quality echo educational courses from

University Hospital of North Staffordshire

An intensive / up-to-date course for the intermediate or advancedlevel sonographer who wishes to expand and consolidate their current

working knowledge of echocardiography in clinical practice.

Moat House HotelStoke on Trent

16-18 March 2011

9 BSE reaccreditation points awarded

Contact: [email protected]

Tel: (01782) 553550

We are grateful to GE Healthcare for their support of this course

Fourth Annual Meeting

ADVANCEDECHOCARDIOGRAPHY


PA G E 39



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queen alexandra hospital

bse administration

bse newsletterseptember

bse accreditation updatespage

echo cryptic crosswordpage

case reportspage

mechanical index relevance

new era