ISSUE 85
A f f i l i a t e d t o t h e B r i t i s h C a rd i o v a s c u l a r S o c i e t y
i n c o r p o ra t i n g t h e B S E N E W S L E T T E R
CONTENTS include:
Ventricular septal rupture complicating
acute myocardial infarction
5
Cardiology Training in Core ECHO: The
Good the Bad and the Ugly
6-9
Front Cover
9
Uni to Quinti The Spectrum of Aortic
Valves
10 - 13
New Guidelines: A Guideline Protocol for
the assessment of Restrictive
Cardiomyopathy
14 - 20
MARCH 2014
2013/14 BSE COUNCIL MEMBERS
ECHO
ISSUE 85
MARCH 2014
CONTENTS
Page 4
Presidents Message
Page 5
Ventricular septal rupture complicating acute
myocardial infarction
Page 6 - 9
Page 9
Cardiology Training in Core ECHO: The Good the Bad
and the Ugly
Front Cover
Page 10 - 13 Uni to Quinti The Spectrum of Aortic Valves
Page 14 - 20 New Guidelines: A Guideline Protocol for the
assessment of Restrictive Cardiomyopathy
Page 21 - 26 Case Reports
Page 27
Conference Report
Page 28 - 30 Echo in Africa
Page 30
Letter to the Editor
Page 31
Lifetime Achievement Award
Page 32
BSE Practical Competence Assessment Pilot
Page 33
BSE Wordsearch
Page 34 - 35 Recently Accredited Members
Page 35
Dates for your Diary
Page 36
Call for Abstracts 2014
OFFICERS
President:
Dr Guy Lloyd
President Elect:
Dr Rick Steeds
Vice President:
Jane Allen
Honorary Secretary:
Jude Skipper
Honorary Treasurer:
Tracy Ryan
ELECTED MEMBERS
Gurpal Bhogal
Dr Adelle Dawson
Dr P Rachael James
Jane Lynch
Dr Jamil Mayet
Dr Thomas Mathew
Dr Jim Newton
Keith Pearce
Dr Bushra Rana
Dr Rick Steeds
Eastbourne DGH
University Hospital Birmingham
York Teaching Hospital
Queen’s Hospital, Essex
Walsall Manor DGH
Russells Hall Hospital, Dudley
Ninewells Hospital, Dundee
Royal Sussex County Hospital
Wythenshawe Hospital, Manchester
St Mary’s Hospital, London
Nottingham City Hospital
John Radcliffe Hospital, Oxford
Wythenshawe Hospital, Manchester
Papworth Hospital
University Hospital, Birmingham
CO-OPTED MEMBERS (1 year term)
Dr Chris Eggett
SCST Representative, Freeman Hospital
Newcastle
Dr Nick Fletcher
ACTA Representative, St.
George’s Hospital, London
Nicky Mills
Industry Representative, Bracco UK
Dr Mark Monaghan
Kings College Hospital, London
Dr Muttucumarasamy Mahendran
Primary Care
Representative, Milton Keynes
Helen Rimington
Academy of Healthcare Science
Representative
Dr Rizwan Sarwar
Jr Dr Representative, John Radcliffe
Hospital, Oxford
Stefanie Bruemmer-Smith
Brighton & Sussex Hospital,
ICS Representative
Gill Wharton
Academy CVRSGUI Professional Group
Representative
Dr Gordon Williams
ECHO Editor York Teaching Hospital
INSTRUCTIONS TO AUTHORS
ECHO is published four times per year. It is the official publication of the British Society of Echocardiography the contact address
is: BSE Administration, Docklands Business Centre, 10-16 Tiller Road, Docklands, London E14 8PX, Tel. 020 7345 5185, Fax 020
7345 5186 Email [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 to [email protected] .
The format should be text as a normal word document and images supplied as high resolution jpeg, tiff, eps or pdf files. Other
formats including powerpoint or of web image construction may result in reduced resolution and may be unacceptable.
Articles should contain appropriate references. References to be constructed with the first two authors, thereafter abbreviate to ‘et
al’, then article title, followed by journal reference.
Submissions to ECHO are currently not peer reviewed but may soon become so, changes will be advised. The Editor has discretion
on acceptance. Patient consent is required for case reports.
It should be noted that opinions expressed in articles or letters are the opinions of the author(s) and not of the council of the British
Society of Echocardiography (BSE). Official BSE council views or statements will be identified as such.
Information in respect of advertisements can be obtained from [email protected].
Editor
PA G E 3
PRESIDENT’S
MESSAGE
N equals one
Earlier this year something momentous happened. After
many years of meetings, lobbying, pressure, arguments,
frustration and disappointment, the first clinical scientist
was officially registered with the Academy for Healthcare
Science. Brian Campbell, President of SCST is the n
equals one. The importance of this cannot be overstated.
After so long, there is now a process whereby clinical
scientists can gain professional recognition. This opens
the door for clinical scientists to play an even more
pivotal role in frontline patient care, and also sets the
stage for the consultant clinical scientists who will be
produced by the Higher Scientific Specialty Training
programs. As graduates from Modernising Scientific
Careers will automatically be entered on to the register,
this will over time become the clear route to professional
recognition.
There is of course a “but” at this point. While the path is
clear for those coming through the MSC approach, it is
much less clear for those already within the profession.
The MSC equivalence route is currently in its trial period,
this was the route by which Brian Campbell was
registered, and all areas of cardiovascular physiology have
been asked to provide a candidate to test the process.
Jane Allen, Vice President of BSE is currently going
through that system and this should provide valuable
insights for those wishing to follow her. Ultimately over
a five year period those who wish to make the transition
should be able to. The requirements are posted on the
Academy website and it is fair to say that at present the
process is quite onerous.
The BSE is lucky to have great representation at all levels
in the Academy which means that we have been
instrumental in forming some of the processes and we
also get a heads up on developments well in advance.
Because many members of our society do not necessarily
possess the academic modules required by equivalence
this will present some problems and there will be more
PA G E 4
than one option for them. It is likely that Higher
Education Institutions will begin to offer academic
modules to allow the current workforce to top up their
portfolio to reach the equivalence criteria. The RCCP
voluntary register will also continue allowing an
alternative route for those who are not aiming for
equivalence through the academy. The one area about
which the BSE remains resolved is that echocardiography
should not be part of the Practitioner role.
In other news
After an unprecedented early response, there are still
places available for the Echo in Africa program. We are
really keen to get as many members of the society
involved either by volunteering or by fundraising for this
ambitious and worthwhile initiative. A range of events
will be announced soon and the fundraising will extend
into next year (this is a more than one year endeavor).
The website will be up and running in the near future and
just giving accounts for those who wish to fundraise will
also be available in the next few weeks. Those who wish
to contribute at the time of their subscription renewal will
have the opportunity to do so.
It is that time when council considers nominations for the
Life achievement award. Potential recipients are
nominated by the membership and decided by council and
conferred both the award and life membership. I would
therefore invite members to nominate those that have
made an outstanding contribution to join Gill Wharton
and Graham Leech, previous worthy awardees. To
nominate someone email [email protected] by 27th
June 2014.
Finally, I am delighted to be able to formally announce
that Rick Steeds was elected unopposed as the next
President of BSE and will take over the rein after the
AGM in October. Rick has been a tireless contributor to
the society and been instrumental in shaping so much that
we take for granted. Most recently he has presided over
an unparalleled increase in the educational output of the
BSE, chairing this committee. He won’t need it, but, I
wish him the best of luck nonetheless.
Guy Lloyd, President
VENTRICULAR SEPTAL
RUPTURE COMPLICATING
ACUTE MYOCARDIAL
INFARCTION
Interventricular septal rupture is an infrequent complication of
acute myocardial infarction in the thrombolysis era,
complicating around 0.2% of ST elevation myocardial
infarctions and is associated with a high mortality (74%)
(Crenshaw et al). Patients typically present with cardiogenic
shock associated with a new harsh, pan-systolic murmur one to
five days following myocardial infarction. Post infarct
ventricular septal defects (VSD’s) are usually associated with
occlusion of the left anterior descending artery (LAD) whereby
the septal defect is located in the mid to apical septum, although
occasionally (as in this case), they are a result of non-LAD
occlusion, typically affecting the basal infero-septum. The
borders of the defect comprise friable, necrotic myocardium and
the size of the defect can range from <1cm to several
centimetres. The size of the defect determines the degree of left
to right shunting and in turn, the likelihood of survival.
Clinically, ventricular septal rupture should be considered in the
post-infarct patient with a sudden deterioration several days
following admission in the presence of a loud, pan-systolic
murmur. In patients with cardiogenic shock, death is virtually
inevitable without definitive surgical treatment. Surgical patch
repair of the defect is challenging due to the friable nature of
the tissue surrounding the defect. Device closure has been
reported but its use is currently reserved for those considered
Legend: Colour Doppler flow imaging highlighting the intraventricular septal rupture.
not suitable for cardiac surgical intervention.
VSD’s can be small and, especially if located apically, difficult
Reference
to identify on transthoracic imaging. For this reason, the
sonographer must have a high index of suspicion for the
presence of a VSD rupture whilst performing the scan. The use
of off-axis views and colour Doppler may be helpful in
Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris
DC, Kleiman NS, Vahanian A, Califf RM, Topol EJ
Risk factors, angiographic patterns, and outcomes in patients
with ventricular septal defect complicating acute myocardial
demonstrating the defect.
infarction. GUSTO-I (Global Utilization of Streptokinase and
Laura Dobson
Monashheart, Melbourne, Australia
TPA for Occluded Coronary Arteries) Trial Investigators.
Circulation. 2000;101(1):27.
PA G E 5
CARDIOLOGY TRAINING in
CORE ECHO:
The Good the Bad and the Ugly
Introduction
Last year, the GMC and BJCA (British Junior Cardiac
Association) national surveys, highlighted major failings in
training in echocardiography. Concerned by this, the SAC
(Specialist Advisory Committee) approached the BSE to
investigate and understand the reasons why this was the case.
The BSE in conjunction with the BJCA held a joint training
day. Over 100 Cardiology trainees attended. The day included a
debate and discussion. In this report we highlight the current
barriers to achieving high quality training, identify the major
stakeholders and consider how UK core echocardiography
training can be improved.
Current Training Format
It is generally agreed that of all the core skills, being able to
perform a transthoracic echocardiogram is the most crucial for
patient management, service delivery and education. The
transthoracic echo is an easily accessible bedside investigation,
which is not only cost effective but allows rapid acquisition of
complex data, accelerating diagnosis and further management.
At a time where the pressures on the NHS continue to intensify,
timely decision-making is key. Limitations in high quality
service delivery hamper patient care in multiple ways and can in
part be attributed to standards in doctor training and acquisition
of essential core specialty skills. With the introduction of
Modernising Medical Careers, reducing total training time by
one year, and implementation of the New Deal and Working
Time Regulations, the working time has been restricted to an
average of no more than 48 hours per week. Although these
changes offer benefits, they also present a number of
challenges; in particular those resulting from tensions between
demands for service provision (with increasing on-call
commitments) and training.
The requirements for core echocardiography training are
specified in the new cardiology curriculum, first introduced in
2007 and updated in 2010; it sets out a clear framework of
knowledge and skills. Trainees must acquire an understanding
of the role of echocardiography in managing patients with
cardiac disease; be able to perform, interpret and report a
transthoracic study; and understand the indications of more
advanced techniques including TOE and stress
echocardiography. Currently practical competency (including
interpretation and reporting skills) can be demonstrated through
completing six directly observed procedural skills assessments
(DOPS) or by achieving BSE transthoracic echocardiography
accreditation. See table 1.
The Issues with current Training
The key issues center around access to formal echo training
lists. At present there is variability in whether a local echo
PA G E 6
trainer is identified to over see the delivery of hands-on
structured training. It seems a lack of a named local echo-trainer
has a negative impact on the quality of training received.
Trainees have also highlighted inconsistencies of Regional
Training Committee expectations of what constitutes core
training in echocardiography and the level of support provide to
the trainee in achieving these goals.
Echo departments are expected to deliver the practical aspects
of core echo training. However, StR training lists are disrupted
by lack of protected time, where StR’s may fail to attend a
training list due to demands elsewhere. Understandably, such
lists are then given out reluctantly. There is a lack of
engagement of senior physiologists in the formal training
programme, yet they are the very people who are expected to
deliver the training.
It is not surprising that this aspect of cardiology training has
been highlighted as a major failing, since it is the only
procedure based training where, at a local level, senior doctors
rarely become involved. While the training from clinical
scientists results in high quality tuition, the lack of medical
input affects the attitudes and culture; resulting in deprioritization of echo training.
The Way Forward
After discussions with SAC, BCS Training Committee and
BJCA, the BSE have suggested the next steps in how these
issues might begin to be addressed. This is summarized in a
letter to the Cardiology SAC and a response is currently
awaited. What is clear is the three key stakeholders(the trainee,
the specialist training committee (STC) led by the Training
Programme Director (TPD), and the hospital/echo lab) all play
an active role in training registrars.Additionally the BSE have a
key role in facilitating the process.However, there appears to be
inconsistencies and confusion in understanding exactly what is
expected of each.It would be useful to re-iterate and clarify
these roles; not only to aid the trainees and those responsible for
training them, as to what they should expect from each other,
but also what they must contribute. A summary of these
suggestions is given in table 2. Some of these points are
discussed in more detail below.A more detailed account will be
published in the fourth coming BSE journal ‘Echo: Research
and Practice’, due to be launched in the coming months.
1. Better access to echocardiography sessions with
appropriate supervision and training.
A lack of access to a regular supervised echocardiography
training list(s) is perceived as one of the major barriers to
achieving good quality training. The reasons for this are
complex. Although some trainees reported very few, or even no
specific training lists offered by echocardiography departments,
in many cases an increased demand and prioritisation of service
commitments and constraints of shift-patterns led to an inability
to attend available sessions. Training sessions delivered were
usually not ‘bleep free’ protected time.Furthermore, trainees felt
that they were not prioritised due to a number of reasons;
staffing constraints, the need to allocate training lists to trainee
physiologists, the significant impact of training on general
workflow. However what is also clear is that non-attendance of
Table 1
How to demonstrate competency in core echocardiography
BSE Transthoracic Accreditation
• Written exam
• Logbook of 250 cases (with specific case mix) collected over 24 months before and after passing exam
Directly Observed Procedure (DOPS) Assessment
• A minimum of 6 DOPS completed by at least 2 different assessors
• BSE curriculum assessment tool (not mandatory)
• Logbook (not mandatory)
Table 2
Stakeholder
Regional Training Committee
• Should provide trainees with clear guidance of what to expect from their local echocardiography departments, including
named echocardiography mentor, responsible for hands-on training and a regular ‘protected time’ (min 1x/week) training
lists with supervision from a physiologist (ideally BSE accredited) or cardiologist.
• Clear guidance as to how to achieve structured training and experience eg BSE accreditation process.
• A regionally appointed echo training director to over see oversee training
• A regionally appointed physiologist to support and facilitate training delivery across the region
• Clear guidance to the trainee as to the appropriate pathway to raise concerns
Local Echocardiography Department/Hospital Trust
• Should offer a formal supervised training session in TTE
• Should identify a training lead (physiologist and/or cardiologist) responsible for ensuring echo training delivery
Trainees
• Should know exactly what is expected of them during core echo training (eg producing evidence through case logbook
collection. BJCA echocardiography toolkit provides a succinct summary of training requirements and proposed time line
to achieve this)11
• Should highlight any issues regarding difficulty in acquiring competencies early in the training process to allow relevant
actions to be taken using the pathway provided by the STC
British Society of Echocardiography
• Should support the delivery of high quality echocardiography training through
- National BSE training days in addition to proposed regional echocardiography courses for core trainees which will
include both core knowledge and simulator training
- Greater emphasis on echocardiography training at BSE conference
- Raising awareness (and offering support) amongst physiologists of the importance and benefits of training
cardiologists
- Develop an updated version of the curriculum based assessment to be submitted in conjunction with DOPS
assessment to achieve core competency
- Development of formal recommendations for guidance on training cardiologists in echocardiography in the UK
an allocated training echo list as an option isn’t acceptable; and
leaves the echo department in difficulties. Therefore any
reluctance on the part of the echo department is understandable.
Therefore, there requires a shift in attitudes, where the STC
clearly mandates the trainee to demonstrate attendance at echo
lists; it would be worth knowing this is in fact already an
expectation in the training programme. The STC should then
actively seek evidence from the trainee that this is occurring.
The hospital staff, from the consultants to the echo department,
acknowledge the mandate to provide a regular protected
training list (at least 1x/week), and preferably provide a senior
trainer; while the trainees recognise that it is expected they
PA G E 7
attend. The excuse (by either the trainee or echo department)
that there is no time to train is of great concern, and while we
acknowledge departments are working under pressure the
importance of training future cardiologists in this core skill
cannot be emphasised enough. There are huge advantages in
encouraging the presence of StR’s in the echo lab. More
complex echo studies (e.g. contrast administration for LV
opacification or agitated saline for assessment of a intracardiac
shunt), as well as valuable dialogue between physiology and
clinical teams is an essential when striving to deliver a quality
service. Further, to facilitate better physiology engagement the
BSE have suggested a regional physiology lead as a
formalisation of their inclusion in the training process. This
would create a dialogue and understanding between the two
groups of the weaknesses and strengths in training within the
region and how this might be addressed.
2. Greater flexibility in BSE TTE Accreditation process
allowing a greater number to trainees to achieve this
standard.
Currently echocardiography competency for cardiology trainees
is assessed through the following mechanisms: (i) knowledge
based assessment exam undertaken at the ST3 stage of training
and (ii) a practical competency assessment (table 1). Practical
competency can be demonstrated either by completing BSE
TTE accreditation or achieving 6 DOPS, completed by 2
different assessors. If trainees chose to use DOPS for
assessment they are strongly encouraged to complete the BSE
curriculum based assessment tool in order to provide evidence
of experience across a breadth of cardiac pathologies.
Data from the 2013 BJCA survey suggests that although many
trainees wish to obtain BSE accreditation, the numbers actually
achieving this are low (26% of all trainees surveyed). Trainees
felt that the requirement for compiling a logbook in a 12 month
period is too difficult to achieve. In addition not all departments
may have the capacity to offer trainees the opportunity to attain
BSE accreditation. In order to try and address this issues BSE
have recently extended the time duration for collating a logbook
to 24 months around the time of the examination; and this
change has been active since October 2013.
echocardiography competency in an appropriate time-frame
It was interesting to note that during the Joint BSE/BJCA
training day discussion, trainees did not have a clear
understanding on the process in which they raised concerns
regarding failure to progress in their echo training; indeed some
feared negative repercussions if they did so. Currently concerns
may be directed to either clinical or educational supervisors,
training programme director or to the annual review of
competence progression (ARCP) panel. The ARCP is the formal
annual process by which a trainee’s progression is reviewed and
assessed. Trainees reported that often echocardiography was not
specifically asked about and when concerns were raised, they
were not necessarily addressed.
The appointment of an Echo director, has been advised by the
Cardiology SAC (Chair Dr Ian Wilson). They would be
responsible for ensuring the trainee had access to regular echo
training lists, through acting as a point of contact for trainees to
raise any concerns, addressing any issues raised and ensuring
training is being delivered to individual trainees to a satisfactory
level. Furthermore greater clarity of what trainees should
practically expect from echocardiography training will also
facilitate this. The key roles of individual stakeholders are
summarised in table 2.
4. Concept of modular training
One key aspect raised by the trainees was the need for early
acquisition of hands-on echo skills. They were keen for StR
entry-level focused training in echocardiography. Some trainees
struggle to obtain the necessary standard in competency, which
if reached to a desired level is acquired late in their training
program. Hence the BJCA are very keen to see the
establishment a modular type approach, where 1-3 months is
spent training in an echo lab performing a high volume of
transthoracic echo studies. This intense focused training will
bring the StR up to speed rapidly, and usefully set the scene for
further development of such skills; hugely benefiting the
trainees and their patients, as well as other staff. However, in
the current system this may not be feasible in all hospitals.
Simulator training has been suggested as a useful adjunct and in
the absence of modular training may help to partially bridge the
gap.
Although it is agreed that BSE accreditation (or its equivalent)
should be mandatory for those who intend to pursue imaging
subspecialty, not all trainees will need or want to undertake this
formal process. However the alternative, of 6 DOPS, may not
be robust enough to ensure proficiency in TTE. Given that
much of the echo training delivered in the UK will be by
physiologist they are not be familiar or trained in this form of
assessments and there is a lack of clarity as to whether they can
complete them. For those pursuing this alternative approach the
BSE assessment tool in addition to an informal logbook may
provide a more comprehensive approach. Therefore, a vital
aspect of supporting such training is clarification of what
exactly is meant by core echo training. Currently, a document
on ‘Training Cardiologists in Echocardiography in the UK’ is
under development, led by Dr Thomas Matthew, BSE Lead for
Trainees.
The BCS have run pilot courses in simulation training, centered
on patient safety. This is proving to be very popular amongst
trainees. The benefits of simulation training have been widely
assessed in medicine and multiple articles exist in the literature.
Simulator based medical education has been shown to be
superior to the traditional didactic system of education 1-3. Six
competencies are defined: patient care, medical knowledge,
practice-based learning, interpersonal skills, professionalism
and system based practice 4, 5. Simulation training has the
potential to facilitate proficiency in all six areas and where
appropriate allows re-creation of clinical scenarios helping
standardize medical education and training. This improved
proficiency leads to better patient care and management with
improved patient outcomes 6, 7. There is no doubt that simulation
based training accelerates learning 8.
3. Identifying and supporting trainees who are not achieving
A number of echo simulator training systems exist1. The most
popular in the UK is Heartworks1. Important features of this
PA G E 8
system include programs in transthoracic and transoesophageal
echocardiography, excellent anatomical virtual imaging along
side echo images, and normal heart studies along with an
increasingly wide range of cardiac pathologies.
References
• Shakil O, Mahmood F, Matyal R. Simulation in
echocardiography: an ever-expanding frontier. J Cardiothorac
Vasc Anesth. 2012 Jun;26(3): 476-85
BSE Initiative
• Hartman GS, Christopher WW, Mullin M, et al: A virtual
The BSE run a national course in echocardiography, Core
Knowledge, which is lecture based and includes case reviews
and discussions. As a direct result of the issues highlighted in
echo training nationally, the BSE are in the process of devising
a echo training course which will be aimed at all core
cardiology trainees and will incorporate core knowledge lecture
series and simulator training. The aim is to engage each training
region to provide a regional simulation training centre(s), once
the trainee has attended a 2 day lecture course. The advantages
of regional engagement in this process are significant. Creating
a forum for echo training and discussion, with the opportunity
to meet the Echo Training Director.
reality transesophageal echocardiography (TEE) simulator to
facilitate under- standing of TEE scan planes. Anesthesiology
95: A545, 2001.
• McGaghie WC, Issenberg SB, Cohen ER, et al: Does
simulation- based medical education with deliberate practice
yield better results than traditional clinical education? A metaanalytic comparative review of the evidence. Acad Med
86:706-711, 2011
• Eason MP: Simulation devices in cardiothoracic and vascular
anesthesia. Semin Cardiothorac Vasc Anesth 9:309-323, 2005
Conclusion
• Okuda Y, Bryson EO, DeMaria S Jr, et al: The utility of
A change in the attitudes and delivery of echo training is long
over due. There is raising momentum and a will to see this
change for the better. By raising awareness of the issues and
providing a clarity as to the responsibilities of each key player
in this fight we will help accelerate the changes needed to
achieve high quality echo training across the UK. Like the SAC
and BCS, the BSE are committed to this and will continue to
increase their efforts. Further national training days are planned;
and under development are: a formal document offering
guidance in echo training; a nationally delivered course with
inclusion of simulator training; and greater emphasis given on
issues specific to trainees at the annual BSE conference. As
always the authors welcome any suggestions on how we can
further these goals.
Anna Kydd and Bushra Rana,
Contributors: Thomas Mathew, Rick Steeds, Guy Lloyd (BSE)
Rizwan Sarwar, Afzal Sohaib, David Holdsworth (BJCA)
simulation in medical education: What is the evidence? Mt
Sinai J Med 76:330-343, 2009
• Barsuk JH, Cohen ER, Feinglass J, et al: Use of simulationbased education to reduce catheter-related bloodstream
infections. Arch Intern Med 169:1420-1423, 2009
• Draycott T, Sibanda T, Owen L, et al: Does training in
obstetric emergencies improve neonatal outcome? Br J Obstet
Gynaecol 113: 177-182, 2006
• Sharma V, Chamos C, Valencia O, Meineri M, Fletcher SN.
The impact of internet and simulation-based training on
transoesophageal echocardiography learning in anaesthetic
trainees: a prospective randomised study. Anaesthesia. 2013
Jun;68(6):621-7
FRONT COVER
Left ventricular pseudoaneurysm
This image demonstrates a left ventricular pseudoaneurysm as a
complication of a late presentation anterior ST elevation
myocardial infarction. Left ventricular pseudoaneursyms are
characterised by localised rupture of the myocardium contained
by the pericardium and organised haematoma, with walls
lacking in myocardial tissue. Due to the friable nature of their
containment, LV pseudoaneuysms are prone to rupture, with
often catastrophic consequences. Prompt identification and
treatment (by surgical repair) is of upmost importance.
Laura Dobson
Monashheart, Melbourne, Australia
PA G E 9
UNI TO QUINTI
obstruction. The term sclerosis is now frowned upon as it is the
forerunner of later organic degenerative valve dysfunction
THE SPECTRUM OF AORTIC VALVES
2. Bicuspid.
For many years aortic valve disease in adults was an acquired
disorder. Little attention was paid to any other alternative, aortic
valves were either normal, rheumatic or syphilitic. Both the
latter have for practical purposes disappeared in the Western
world, with age related degenerative diseases replacing them.
However, aortic valve disease presenting in younger adults is,
through the medium of available and quality non-invasive
imaging, recognised frequently to be related to congenetal aortic
valve pathology.
Severe congenital conditions present in the newborn or in early
infancy and generally are a different pathology or grade of
severity to the congenital conditions which do not manifest
themselves until late teenage or adult life. I will therefore be
referring only to the adult presenting aortic valve disorders.
1. Tricuspid aortic valve
Consider initially the descriptive terminology of the valve
structure.
a) Cusp. This strictly describes the edge or tip of a leaflet
although the term is often used in the context of leaflet.
A Bicuspid Aortic Valve (BAV) is the commonest congenital
abnormality occurring in up to 2% of the general population
with a predominance in males. Although seen relatively
frequently in an echo department the condition often gives rise
to questions of doubt or debate. The reason for this relates to
the number of variations of bicuspid aortic valve structure.
Here, terminology is important so that describing the image
findings is essential to the correct image interpretation. The
cusp, leaflet and commissural terms have already been
mentioned but a fundamental additional term is:
d) Raphe. This term is used to describe “fusion”. With
underdeveloped leaflets, their edges are or can be fused
together resulting in a thickened abnormal commissural ridge
between the abnormal leaflets. This fusion of the two
underdeveloped leaflets may result in them functioning
together as a single leaflet . With the other unaffected leaflet
the valve in effect functions as a two leaflet or bicuspid valve.
A” pure”BAV will have two similarly sized leaflets with
nothing fused, hence no raphe. Rather than the term” pure”,
this variant has been termed type “ 0” (no raphe).The
catagorisation refered to is that of Sievers et all 1. It should at
this point be appreciated that there are a number of different
catagorisations of BAVs with different terminology.
b) Leaflet. This is the more appropriate term for the structural
elements or components of the valve
These terms can be used interchangeably e.g. tricuspid or tri
leaflet, but traditionally the term cusp is the accepted
descriptive term, describing the number of components to the
valve i.e. bicuspid or tricuspid etc.
A normal or tricuspid aortic valve (also known as a semilunar
valve) has three equal edges of parallel cusp apposition.
c) Commissure. This traditionally describes the free edge of a
valve leaflet. Leaflet edges are in apposition when leaflets
close.
This article is not intended to describe aortic valve dysfunction.
However, it is appropriate to discuss briefly age-related changes
to an originally normal tricuspid aortic valve. This is in the
context that such changes can result in imaging interpretation
difficulties when considering whether or not a pathological
valve was initially tricuspid or bicuspid. Another common
situation is the so-called “ sclerotic”aortic valve in which there
is some thickening and fibrosis of the leaflets and or
commissure edges resulting in a flow murmur although the
valve opens satisfactorily without causing measurable
PA G E 10
The variant described above with the fusion of two small
underdeveloped leaflets fused by one raphe has been termed1
(referring to one raphe) using the Sievers terminology.
In addition to a raphe fusing the commissural edges of two
underdeveloped cusps there may also (relatively rarely) be an
additional raphe fusing one edge of one of the smaller leaflets to
the leaflet edge of the one larger normal cusp. This results in 2
raphes and this variant has been termed a type 2 BAV. The
simple diagram (figure 1) depicts these BAV variants.
0 raphes -
Type 0
1 raphes -
Type 1
2 raphes -
Type 2
Fig. 1. Types 1 and 2 although having identifiable albeit two
smaller leaflets, the fusion results in them being effectively
only two functional leaflets. Type 1 is by far the commonest
variant.
Although bicuspid valves are structurally abnormal they
generally function satisfactorily until the fibrous raphe and
commissural edge thickening becomes more extensive resulting
in restrictive valve opening, hence developing aortic stenosis.
Stenosis is the commonest presentation albeit invariably with
some regurgitation. To have regurgitation as the dominant
functional defect occurs in less than a third of cases.
The median age for requiring an aortic valve replacement is in
the mid 30s, highlighting the importance of intermittent followup and reassessment once a BAV has been recognised (which is
currently usually in childhood).
Bicuspid valve’s are associated with a significant tendency to be
accompanied by developing aortic root dilatation which may
extend up to the aortic arch. Originally, when it was recognised
that the aortic wall structure associated with BAV’s was “
thinner”than the normal three layered aortic wall there being a
relative absence of the middle or median muscular layer, the
term”cystic medial necrosis” was utilised. This phrase is still
often used mainly by habit although the basis for the defect is
genetic with variant phenotypical developmental abnormalities
rather than a necrotic process.
Although most cases of BAV are incidental or sporadic, it is
also recognised that there may be a familial association in as
many as 15% of close relatives. Expressing this another way, in
one study of 30 families of patients with BAV they found 11
families (37%) had more than one first-degree relative with a
BAV (Chan et al 2 ).
Some genes have been identified in the inheritance of BAV one
being NOTCH1 with others being more recently identified
demonstrating genetic heterogenicity and complex inheritance.
The practical relevance is that the aorta may well be involved
and requires study and measurement at the time of each echo
assessment for BAV as it is the “rate of change”of the aortic
when the route dimensions on echo are reaching the point of
concern a thoracic CT scan will be required to assess the
ascending aorta and aortic arch for dilatation. Invariably, expect
to find some, albeit slight, variation between the CT and Echo
measurements of aortic dimensions due to technique
differences. This should not be interpreted as an error but is to
be expected.
It should be appreciated that aortic root dilatation is a distinct
entity and is not dependant on the degree of aortic valve
dysfunction.
Given that a BAV is associated with aortic pathology , it is not
surprising that aortic pathology further round the aortic arch,
namely a coarctation of the aorta is also a common associated
defect accompanying a BAV. Hence, interrogation of the
descending thoracic aorta for evidence for or exclusion of
coarctation is a mandatory requirement for an echo study
involving a BAV.
Any structural cardiovascular defect resulting in a surface
irregularity of the endothelial lining of a heart valve is a
potential site for bacteria to settle resulting in endocarditis. BAV
is no exception with endocarditis being relatively common.
Finally, when recognising a BAV on Echo, if it is of the pure
type (type 0 ) with two cusps and no raphe the cusp apposition
line can be lateral or antero- posterior. The common type of
BAV ,type 1, with fusion of two smaller cusps with one larger
cusp with one central raphe the direction of the effective two
cusps is rarely anteroposterior and more often latero- lateral
with the raphe aligned with the centre or middle of the greater
cusp. When the closure line is latero- lateral, the right coronary
artery usually originates from the right sinus of Valsalva and the
left main stem from the left sinus. When the BAV’s orientated
Bicuspid aortic valve
Commissure
Single
cusp
Raphe
Conjoined
cusp
Fig. 2. Drawing of a BAV looking down from the aorta
demonstrating one normal cusp with 2 cusps fused by a
fibrous "raphe". The coronary ostea are apparent.
root dimensions rather than the absolute values which direct the
timing of surgery for an aortic root replacement. To assess how
much of the ascending aorta and aortic arch may be involved,
Fig. 3. A bicuspid valve at the time of surgery with the arrow
highlighting the raphe.
with the closure line antero posterior both coronary arteries may
have a common origin from the anterior sinus. Rarely this has
been reported to be associated with sudden cardiac death during
exercise. Hence, without propagating alarm it is appropriate to
report the orientation of the valve in the Echo report.
PA G E 11
TOE examination, some not being recognised until surgical
excision.
Bicuspid valves are well known to have an increased
association with aortic dissection but unicuspid valves even
more so. In an autopsy study of 161 cases of aortic dissection
the risk of dissection associated with a bicuspid valve was 9
times and with a unicuspid valve 18 times that of subjects with
a tricuspid aortic valve ( Larson et al 4). Emphasis therefore is
Type 0
(No Raphe)
20%
9%
Type 1
Type 2
(One Raphe)
(Two Raphes)
59%
10%
2%
Fig. 4. Frequency of distribution of BAV types.
3)Unicusp
The presence of only one aortic valve cusp was for many years
only detected either at surgery for an aortic valve replacement
or as an incidental post-mortem finding. Echocardiography
change that with reports of recognition initially in childhood but
but now occurring as adult case reports (Krishnamoorthy 3)
Presumably, as with by bicuspid valve leaflets which are
structurally abnormal, the single cusp of a unicuspid valve
thickens and becomes fibrotic at a much earlier age than normal
tricuspid valve cusps. Hence presentation with aortic stenosis
has been the consistent clinical presentation. The time of
presentation is in early adult life with approximately 50% of
cases reported requiring an AVR in their mid 30s. A degree of
aortic regurgitation invariably coexists. The other notable
feature, again similar to bicuspid aortic valves is the
predominance of males and a strong association with dilatation
of the ascending aorta.
The incidence of unicuspid aortic valves is low and reported to
be between 0.9% and 6% in various series of patients
undergoing aortic valve replacement. The mechanism of
function of a unicuspid valve is generally that of the single cusp
being attached posteriorly between the usual position of the non
and left coronary cusps. Occasionally some valves are
described as having or being a single membrane like leaflet with
a central valvular orifice. Most however are leaflet like having
an eccentric opening area along its free edge opposite its side of
attachment. Distinguishing this on echo from a bicuspid valve
which is functionally unicuspid i.e. a”pseudo”unicuspid valve
from fusion, fibrosis or calcification of one of the two bicuspid
valve leaflets can be difficult at best or impossible even on a
Fig. 5. Diagramatic
illustration of a unicuspid
aortic valve.
PA G E 12
Fig. 6. A short axis parasternal view of a BAV in diastole. The
2 fused cusps are of different size.
Fig. 7. A bicuspid aortic valve with 2 equal sized aortic
leaflets
Fig. 8. A bicuspid valve withone raphe illustrating early
calcification of the 2 abnormal leaflets
on recognition, measurement and trends of progression of the
ascending aorta in unusually looking aortic valves which may
be bi or unicuspid.
4) Quadricuspid.
Quadricuspid aortic valves, recognised as incidental findings
have been published as case reports in previous editions of
Echo. They are reported to be rarer than unicuspid aortic valves.
In terms of quadricuspid semi-lunar valves, quadricuspid
pulmonary valves are reported to be nine times more common
than quadricuspid aortic valves. A quadricuspid pulmonary
valve almost always appears to function normally and generally
are detected incidentally at post-mortem. Quadricuspid aortic
The coronary ostea may be misplaced and cause surgical
problems at the time of an aortic valve replacement. There has
been at least one case report of sudden death in a teenager due
to coverage of the left coronary ostea by leaflet tissue in a
quadrant has valve.
Interestingly the quadricuspid aortic valve is not reported to be
associated with developing aortic root or ascending aortic
abnormality and only rarely are quadricuspid valves reported to
be a site for endocarditis.
Although patients with a BAV not uncommonly also have a
bicuspid pulmonary valve it is interesting that no patients have
been reported to have simultaneously both a quadricuspid aortic
and pulmonary valve.
5) Quinticuspid. To have 5 aortic valve cusps is very rare with
to date only three case reports of this anomaly (Bogers et al 5).
Therefore, although unlikely, it is always worth keeping an eye
open for.
The variants of human anatomy continue to be ever fascinating.
Gordon Williams
Editor
References
Fig. 9. A quadricuspid aortic valve with 4 equally sized cusps
imaged in diastole
1. A classification system for the bicuspid aortic valve from 304
surgigal specimens. Sievers H-H and Schmidtke C
J Thoracic Cardiovasc Surg 2007;133:1226
2. A prospective study to assess the frequency of familial
clustering of congenital bicuspid aortic valve.
Huntington K, Hunter AG, Chan KL
J Am Coll Cardiol, 1997; 30, 1809
3. Images in Cardiology: Unicuspid aortic valve
Krishnamoorthy KM
Heart 2001; 85:217
Fig. 10. The same valve as fig 9 seen in systole with the 4
equally sized leaflets fully open.
valves, presumably because of their high pressure environment
do become dysfunctional in adult life predominantly with
incompetence with the requirement for an aortic valve
replacement being slightly later in age than for a bicuspid valve.
The valve structure of a quadricuspid aortic valve is generally
that of three equal sized cusps and one smaller cusp, the next
most frequent combination being 2 equal sized larger cusps and
2 equal smaller ones and finally just 4 equal sized cusps. Again,
these quadricuspid valves occur more commonly in males.
4. Risk factors for aortic dissection: a necropsy study of 161
cases.
Larsen EW, Edwards WD
Am J Cardiol 1984;53:849
5. Quinticuspid aortic valve causing incompetence and stenosis
Bogers AJJC, Zulfukar A, Hendriks FFA, Huysmans HA
Thorax 1982;37:542
PA G E 13
NEW GUIDELINES
A guideline protocol for the assessment of restrictive cardiomyopathy
Lead Authors
Dr. D. Knight, Dr. K. Patel, Dr. C. Whelan
Education Committee Authors
Dr Rick Steeds (Chair), Will Bradlow, Alison Carr, Richard Jones, Prathap Kanagala, Daniel Knight, Guy Lloyd, Thomas Mathew, Navroz
Masani, Kevin O’Gallagher, David Oxborough, Bushra Rana, Liam Ring, Julie Sandoval, Martin Stout, Gill Wharton, Richard Wheeler
1. Introduction
1.1 The BSE Education Committee has 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 Understanding restrictive cardiomyopathy (RCM).
This document gives recommendations for the image and analysis dataset required in patients being assessed for restrictive cardiomyopathy
(RCM). RCM is a functional classification that is made on the basis of adverse filling of the left ventricle and is therefore different from the
structural changes that describe other forms of cardiomyopathy (such as hypertrophic or dilated). RCM can either be primary or more commonly
secondary to various conditions (see table) adversely affecting the filling pattern of the left ventricle. The natural histories of conditions causing
myocardial restriction exhibit a spectrum of cardiac pathophysiology from subclinical (including the early stages of diastolic dysfunction) through
to severely restrictive diastolic filling patterns. Thus the operator should take care to interpret more subtle findings that may be the only
manifestations of disease development, with novel deformation imaging assisting in the identification of early disease states.
The morphological and anatomical features of causative pathologies in RCM can be indicative but not specific of an underlying disease state. The
majority of RCMs are secondary to systemic aetiologies, the commonest of which is amyloidosis. In contrast, idiopathic (primary) RCM is rare.
The term amyloidosis describes a group of disorders caused by abnormal folding, aggregation and accumulation of certain proteins in the tissues,
in an abnormal form known as amyloid deposits. This document gives recommendations for the image and analysis dataset required in patients
being assessed for RCM with a particular reference to cardiac amyloidosis and the transthoracic echocardiography protocol performed at The UK
National Amyloidosis Centre (NAC), with whom this guideline has been co-authored (http://www.ucl.ac.uk/medicine/amyloidosis).
While echocardiography allows a comprehensive assessment in RCM, it is important to remember the complementary role of other imaging
modalities, including cardiac MRI.
Primary
Idiopathic
Secondary
Infiltrative disorders
• Amyloidosis
• AL: cardiac involvement common.
• Transthyretin (ATTR): familial variant, usually autosomal dominant.
• Age-related: senile in 25% aged > 80 years (Wild Type ATTR); atrial in 90% aged > 90 years (deposits derived
from atrial natriuretic peptide, ANP).
• AA: cardiac involvement rare.
• Haemosiderosis (for example: haemochromatosis, transfusion-related iron overload)
• Sarcoidosis
Endomyocardial fibroelastosis
Scleroderma
Radiotherapy
Adapted from Nihoyannopoulos & Dawson, European Journal of Echocardiography
PA G E 14
(2009) 10, iii23–iii33
1.4 The distinction between concentric remodeling versus concentric hypertrophy (see figure) is an important concept that is poorly
understood, but is of prognostic significance in patients with preserved left ventricular ejection fraction.
The distinction requires the calculation of relative wall thickness (RWT) and LV mass using the following formulae:
RWT = (2 x LVPWd) ÷ LVIDd
LV mass = 0.8 x {1.04 x [(LVIDd + LVPWd + IVSd)3 - (LVIDd)3]} + 0.6 g
Where LVIDd = left ventricular internal dimension in diastole, LVPWd = left ventricular posterior wall width in diastole, IVSd =
interventricular septal width in diastole.
RWT is increased (≥ 0.42) in both concentric remodeling and hypertrophy, but in infiltrative cardiomyopathy the important
distinction is the increased left ventricular mass (>95 g/m2 in females, >115 g/m2 in males). Conversely, the measurement of RWT in
cases of increased LV mass allows the distinction between concentric (relative wall thickness ≥ 0.42) and eccentric (< 0.42)
hypertrophy.
1.5 The views and measurements are focused upon RCM and are supplementary to those outlined in the minimum dataset. These are
given assuming a full study will be performed in all patients.
1.6 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.
1.7 This document is a guideline for echocardiography in the assessment of RCM and will be up-dated in accordance with changes
directed by publications or changes in practice.
2. List of abbreviations
2.1 Views:
PLAX
A4C
A5C
SSN
parasternal long axis
apical four chamber
apical five chamber
suprasternal
PSAX
A2 C
SC
ALAX
parasternal short axis
apical two chamber
subcostal
apical long axis or apical three chamber
PW
pulse wave Doppler
CW
continuous wave Doppler
CFM
colour Doppler
TDI
tissue Doppler imaging
LA
AV
LVOT
RA
RVOT
RL/RU/LL/LU PV
IVC
LVIDd/s
LVPWd
RVd
RWMA
MAPSE
left atrium
aortic valve
left ventricular outflow tract
right atrium
right ventricular outflow tract
right lower/right upper/left lower/left upper pulmonary vein
inferior vena cava
left ventricular internal dimension in diastole/systole
left ventricular posterior wall width in diastole
right ventricular cavity diameter in diastole
regional wall motion abnormality
mitral annular plane systolic excursion
2.2 Modality:
2.3 Measurement and explanatory text:
LV
MV
Ao
RV
PV
L/R PA
TV
STJ
IVSd/s
PHT
VTI
TAPSE
left ventricle
mitral valve
aorta
right ventricle
pulmonary valve
left/right pulmonary artery
tricuspid valve
sinotubular junction
interventricular septal width in diastole/systole
pressure half-time
velocity time integral
tricuspid annular plane systolic excursion
A ‘*’ indicates that these findings, particularly when found together within an individual echo study, are strongly suggestive
of cardiac amyloidosis
PA G E 15
VIEW
Modality Measurements
Explanatory note for ARVC
PLAX
2D/Mmode
LV dimensions
(LVIDs, LVIDd)
LV cavity size may be normal or small
LV wall thickness
(IVSd, LVPWd)
May be normal
If > 12 mm concentric thickening in the
absence of other pathology (for example,
hypertension, HCM or significant aortic
stenosis) may suggest infiltrative disease
Note: AL Amyloidosis particularly causes LV
increased wall thickness in the mild to moderate range whereas TTR causes LV
increased wall thickness in the moderate to
severe range (although there is overlap)
LV mass
LV mass = 0.8 x {1.04 x [(LVIDd + LVPWd +
IVSd)3 - (LVIDd)3]} + 0.6 g
Care should be taken to ensure accurate 2D
measurements, as errors are amplified by
cubing when calculating LV mass
Relative wall thickness
Relative wall thickness = (2 x LVPWd) ÷
LVIDd
In infiltrative cardiomyopathy there is concentric hypertrophy
*Granular or speckled
appearance of
myocardium
Although this feature is known to be a characteristic feature of cardiac amyloidosis, it is
not a specific finding and hence should not
be used in isolation
Note: Low dynamic range, low grey scale
compression and harmonic imaging can
mimic this appearance. Turning off ‘harmonic’
settings may help to reduce over diagnosis
*Aortic and mitral
valve leaflet thickening
Homogenous thickening of leaflets of all
valves often seen in amyloidosis
Note: Caution should be taken in this qualitative assessment when using harmonic
imaging, which may give rise to the appearance of valve leaflet thickening (see note
above)
PSAX
2D
*Pericardial and pleural
effusions
Frequently, trace or small pericardial and
pleural effusions are seen
LV wall thickness at 4
points using clock face
as reference (12, 3, 6,
9)
2D frozen image at mid LV level at end diastole to demonstrate concentric increased
wall thickness
Note: Avoid inclusion of papillary muscles
when measuring LV wall thickness by 2D
caliper
PA G E 16
Image
Apical 4CH
Apical 4CH
and 2 CH
2D
2D
EF (Simpson’s Biplane)
Reduced in end stages, but may be normal
or mildly reduced in early disease
*IAS thickening
Visual assessment
*Mitral and tricuspid
valve leaflet thickening
Visual assessment: homogenous thickening
RA and LA volumes
and areas
Measured at end ventricular systole and BSA
indexed
Biatrial dilatation: RA area> 19cm_, LA volume>28ml/m_
Apical 4CH
M-mode MAPSE
MAPSE<10mm
Reduced longitudinal function may be seen
before deterioration in global function
assessed by EF
Apical 4CH
PW
Doppler
MV inflow pattern:
E/A ratio
Severe diastolic dysfunction is more suggestive of an underlying restrictive cardiomyopathy. Earlier in the natural history of
restrictive disease, abnormalities of LV filling
by PW Doppler of mitral inflow may be in
the mild or moderate categories of diastolic
dysfunction. Please refer to the BSE diastolic
function assessment guidelines
E deceleration time
Short deceleration time.
Note: normal diastolic filling is extremely
rare in cardiac amyloidosis
Mitral annulus:
In restrictive filling:
e’
Restrictive filling pattern with low e’
e’/ a’
e’/ a’ << 1
E/e’ Sept and Lat
E/e’ (average of septal and lateral mitral
annulus) > 13
Apical 4CH
PW TDI
Earlier in the natural history of restrictive disease, abnormalities of mitral annular PW TDI
may be in the mild or moderate categories
of diastolic dysfunction. Please refer to the
BSE diastolic function assessment guidelines
PA G E 17
s’
Reduced systolic velocity.
Reductions in TDI systolic and diastolic
indices typically occur earlier in the natural
history of the amyloid disease process than
traditional echocardiographic measures, and
may be a subclinical marker when this condition is suspected
Apical 4CH
PW
Doppler
PV flow:
PVs/PVd
PVa
adur - Adur
In restrictive filling:
PVs << PVd
≥ 0.35 m/s
≥ 20 ms
Apical 5CH
PW or
CW
Doppler
IVRT
Short IVRT (<50ms) is in keeping with
severe restrictive filling, but in earlier stages
of the disease process may be prolonged or
pseudonormal. Please refer to the BSE diastolic function assessment guidelines
IVRT is quantified as the time interval
between the end of LVOT ejection and the
onset of mitral inflow. This can be quantified
by PW or CW Doppler to record both mitral
inflow and LVOT outflow velocity profiles:
- PW Doppler: position the sample volume
within the LVOT, but in close proximity to the
anterior mitral valve leaflet
- CW Doppler: position the Doppler beam in
a hybrid position that captures mitral inflow
and LVOT outflow
Subcostal
2D
RV free wall thickness
M-mode
M-mode or 2D frozen image with zoom at
end-diastole at the level of the tricuspid
valve chordae tendinae
≥ 5 mm RV free wall thickening is abnormal
and is frequently seen in cardiac amyloidosis
The administration of intravenous agitated
saline may assist in situations where endocardial definition is poor
PA G E 18
Apical 4CH
and 2Ch
Deforma Global and peak longition
tudinal systolic strain
imaging (optional but extremely
useful)
Reduced with relative apical sparing, giving
rise to a characteristic ‘bull’s eye’ appearance on speckle tracking software*
Ensure high quality, optimized views for
speckle tracking post-processing. This should
result in a frame rate that is commensurate
with optimal speckle tracking (at least > 80
fps)
Reductions in strain indices typically occur
earlier in the natural history of the amyloid
disease process than traditional echocardiographic measures, and may be a subclinical
marker when this condition is suspected
Due to inter-vendor variability, ‘cut-off’ values are not currently advised, but must be
interpreted relative to normative data for
individual speckle tracking packages
References
1. Elliott P, Andersson B, Arbustini E, Bilinska Z, Cecchi F, Charron P, et al. Classification of the cardiomyopathies: a position
statement from the European Society Of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J.
2008;29:270-6.
2. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification: a
report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification
Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society
of Cardiology. J Am Soc Echocardiogr. 2005;18:1440-63.
3. Nihoyannopoulos P, Dawson D. Restrictive cardiomyopathies. European journal of echocardiography : the journal of the Working
Group on Echocardiography of the European Society of Cardiology. 2009;10:iii23-33.
4. Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA. Recommendations for quantification of Doppler
echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the
American Society of Echocardiography. J Am Soc Echocardiogr. 2002;15:167-84.
Further reading about cardiac amyloidosis and evidence for novel techniques for assessing myocardial function
1. Banypersad SM, Moon JC, Whelan C, Hawkins PN, Wechalekar AD. Updates in cardiac amyloidosis: a review. Journal of the
American Heart Association. 2012;1:e000364.
2. Devereux RB, Alonso DR, Lutas EM, Gottlieb GJ, Campo E, Sachs I, et al. Echocardiographic assessment of left ventricular
hypertrophy: comparison to necropsy findings. The American journal of cardiology. 1986;57:450-8.
3. Dungu JN, Anderson LJ, Whelan CJ, Hawkins PN. Cardiac transthyretin amyloidosis. Heart. 2012;98:1546-54.
4. Hu K, Liu D, Herrmann S, Niemann M, Gaudron PD, Voelker W, et al. Clinical implication of mitral annular plane systolic
excursion for patients with cardiovascular disease. European heart journal cardiovascular Imaging. 2013;14:205-12.
5. Koyama J, Ray-Sequin PA, Falk RH. Longitudinal myocardial function assessed by tissue velocity, strain, and strain rate tissue
Doppler echocardiography in patients with AL (primary) cardiac amyloidosis. Circulation. 2003;107:2446-52.
6. Milani RV, Lavie CJ, Mehra MR, Ventura HO, Kurtz JD, Messerli FH. Left ventricular geometry and survival in patients with
normal left ventricular ejection fraction. The American journal of cardiology. 2006;97:959-63.
7. Phelan D, Collier P, Thavendiranathan P, Popovic ZB, Hanna M, Plana JC, et al. Relative apical sparing of longitudinal strain
using two-dimensional speckle-tracking echocardiography is both sensitive and specific for the diagnosis of cardiac amyloidosis.
Heart. 2012;98:1442-8.
8. Pinney JH, Whelan CJ, Petrie A, Dungu J, Banypersad SM, Sattianayagam P, et al. Senile systemic amyloidosis: clinical features
at presentation and outcome. Journal of the American Heart Association. 2013;2:e000098.
9. Rahman JE, Helou EF, Gelzer-Bell R, Thompson RE, Kuo C, Rodriguez ER, et al. Noninvasive diagnosis of biopsy-proven
cardiac amyloidosis. Journal of the American College of Cardiology. 2004;43:410-5.
PA G E 19
10. Rapezzi C, Merlini G, Quarta CC, Riva L, Longhi S, Leone O, et al. Systemic cardiac amyloidoses: disease profiles and clinical
courses of the 3 main types. Circulation. 2009;120:1203-12.
11. Rapezzi C, Quarta CC, Riva L, Longhi S, Gallelli I, Lorenzini M, et al. Transthyretin-related amyloidoses and the heart: a
clinical overview. Nature reviews Cardiology. 2010;7:398-408.
12. Selvanayagam JB, Hawkins PN, Paul B, Myerson SG, Neubauer S. Evaluation and management of the cardiac amyloidosis.
Journal of the American College of Cardiology. 2007;50:2101-10.
13. Wenzelburger FW, Tan YT, Choudhary FJ, Lee ES, Leyva F, Sanderson JE. Mitral annular plane systolic excursion on exercise:
a simple diagnostic tool for heart failure with preserved ejection fraction. European journal of heart failure. 2011;13:953-60.
Letters
to the
Editor
To enhance ECHO both for the authors of
submissions and for other readers,
if you have any views regarding items
appearing in ECHO please write to the editor.
Publishing your views and comments,
inviting responses from authors and
readers can make ECHO an even
more enjoyable and informative
publication.
P leas e email t he edit or at :
[email protected]
PA G E 20
CASE REPORTS
1) Late presentation
Marfan’s syndrome
A 33 year old Caucasian male was admitted with a 4 week
history of sporadic severe chest pain which was exacerbated
with anterior movement. He had a 2 month history of, persistent
cough, SOB and was diagnosed with bilateral pneumonia and
hypertension. This patient also had a high occurrence of self
discharge. His long term history divulged an ocular lens
dislocation aged 4 and a spinal malformation diagnosed aged 13.
At this admission his 12 lead ECG revealed Sinus tachycardia
(105 bpm) with RBBB. Auscultation yielded an apex to right
jugular ESM with chest X- ray indicating cardiomegally leading
to a 2D TTE referral for: Collapsing pulse ?Severe
AR/dissection.
Fig. 2. Subcostal view with focus on abdominal aorta
highlighting extent of the dissection.
fragmentation, myxoid change and dissection. This
histopathological analysis pinpoints Marfan’s syndrome as the
causative factor of the cardiac abnormalities noted.
Following uneventful post surgical recovery the patient was
discharged 7 days later. A subsequent 5 month follow up 2D
TTE performed at the tertiary centre demonstrated a notable
improvement in cardiac status showing good left ventricular
systolic contractility with normal cavity size and mild
concentric hypertrophy. The bi-leaflet mechanical aortic
prosthesis was well seated with trivial “washing jet”
regurgitation. Ascending aorta and arch were normal in size
with dilated descending aorta as previously noted pre surgery.
Discussion
Fig. 1. PLAX view highlighting dilated aorta with poor AV
coaptation and intimal tear (dissection).
Portable, bedside, 2D TTE demonstrated a severely dilated
aortic root measuring; 8cm (Figure: 1) with associated
malcoaptation of the aortic valve leading to severe free flowing
aortic regurgitation (AR PHT = 133ms).
A sub acute type: A dissection was evident with a prominent
dissection flap with independent movement and an associated
false lumen noted in numerous views.
The ascending and descending aorta were also severely dilated
with the associated dissection being noted in the suprasternal
(Figure: 2) and subcostal views (Figure: 3) highlighting the
length and severity of the intimal tear throughout the aorta.
Marfan syndrome is a systemic disorder of connective tissue
caused by mutations in the extracellular matrix protein fibrillin
1 with a UK incidence of 2-3 per 10,000 individuals2. It is a
multisystem disorder occurring worldwide with no predilection
for either sex with manifestations typically involving the
cardiovascular, skeletal and ocular systems. Cardiac
manifestations within the heart are confined to thickening
and/or prolapse of both the mitral and/or tricuspid valve and
aortic valve dysfunction3. This is generally a late occurrence,
attributed to stretching of the aortic annulus by an expanding
root aneurysm.
The left ventricle was severely dilated (LVIDd = 7.3cm) due to
the longevity of the undiagnosed severe aortic regurgitation
with moderately impaired systolic contractility (EF = 42%) as a
by-product of the low flow coronary perfusion attributed to the
dilated sinus of valsalva and consequent malcoaptation of the
aortic cusps.
The patient was transferred to a local tertiary centre for aortic
root, ascending aorta and hemi-arch replacement that was
completed within 24 hours following diagnosis.
Subsequent histological analysis of the native tissue, the aortic
valve showed myxoid change and focal fibrosis. Ascending
aorta histology showed medial degeneration, elastin
Fig. 3. Suprasternal view of aortic dissection initmal tear.
PA G E 21
Marfan accounts for the majority of cases of aortic dissection in
< 40 year olds.
The diagnosis of aortic dissection has been missed in up to 30%
of patients on initial evaluation, and in up to 28% of patients the
diagnosis has been first established at post mortem
examination3.
Marfan syndrome mortality from complications of aortic root
dilatation has decreased (70% in 1972, 48% in 1995) and life
expectancy has increased (mean ± SD) age at death 32 ± 16
years in 1972 versus 45 ± 17 years in 19981.
2D TTE is the favoured modality in routine follow up of
Marfan patients, with CT angiography and MRI providing more
accurate images of the proximal aorta and are commonly
utilised. The sensitivity and specificity of 2D TTE for the
detection of aortic dissection range from 35 to 80% and 39 to
96%, respectively depending on the anatomic location of the
dissection3.
Conclusion
It is poignant to highlight the late diagnosis of Marfan’s
syndrome in this case due to the patient’s high incidence of self
discharge in addition to the severity of the aortic intimal tear
and its ability to be viewed via the images obtained in the
standard 2D TTE BSE protocol.
The post surgery 2D TTE highlights the ability of the heart to
convalesce following significant trauma and to return to near
normal size and function.
No additional follow up imaging is available as this patient has
continued to fail to attend many outpatient clinic appointments.
Jonathan Eldridge, Alison Carr, Chris Gale
Pinderfields general hospital
References
1. Gray JR., Bridges AB et al. Life expectancy in British
Marfan syndrome populations. Clinical Genetics. 1998, 54,
pp. 124–8.
2. Judge, D.P., Dietz, H.C. Marfan’s syndrome. Lancet. 2005.
366 (9501), pp. 1965-1976.
3. Khan, I.A., Nair, C.K. Clinical, diagnostic and management
perspectives of aortic dissection. Chest journal. 2002. 122 (1).
2) Percutaneous closure of
aortic paravalvular
regurgitation under
transoesophageal
echocardiography (2D and
3D) guidance
Paravalvular regurgitation is an uncommon complication of
aortic valve replacement. Clinical consequences are heart
failure, arrhythmias and haemolysis. The risk of a re-do
operation, which usually involves replacement of the dehiscence
valve, carries a significant risk, especially in patients who have
also undergone CABG. Percutaneous approach using vascular
plug (Fig. 1) is a new promising technique. We describe a case
of percutaneous closure of severe paravalvularaortic
regurgitation, in a 65 years old male patient. He underwent an
aortic valve replacement with a bioprosthetic valve and triple
Fig. 1.
PA G E 22
Fig. 2.
Fig. 3.
coronary artery bypass surgery 3 years ago. He presented to the
cardiology clinic with heart failure symptoms. TTE and TOE
(Fig. 2) and aortography (Fig. 3) confirmed severe paravalvular
aortic regurgitation. According to EUROSCORE 2 model, the
risk of a second surgical approach was significantly high (
~5% risk of death). Therefore a percutaneous closure using
Amplatzer vascular plug III was proposed. The procedure was
Fig. 6.
Fig. 4.
Fig. 5.
performed under general anaesthesia with fluoroscopy and TOE
guidance.The role of echocardiography (TOE) 2D and 3D was
important in guiding the operator during the procedure and to
confirm optimal deployment (Figs. 4, 5) minimising possible
complications. The degree of regurgitation was remarkably
reduced as demonstrated by TOE (Fig. 6) and fluoroscopy (Fig.
7). The improvement in the clinical status was also significant (
from NYHA class 3 to class 1). Percutaneous closure of
paravalvular leaks using vascular plug is a new technique which
avoiding the risk ofrepeat surgery and reducing the hospital
stay. Transoesophageal echocardiography has a pivotal role
during the procedure.
Fig. 7.
C. Voukalis, M. Been, V. Dhakshinamurthy,
D. Hildick-Smith
University Hospital of Coventry and Warwickshire
3) AcuNav V intra-catheter
echo in the role of
transcatheter aortic valve
implantation (TAVI)
Interventional centres have adopted 2D and 3D intracardiac
echocardiography (ICE, using Acunav V) in preference to
transoesophageal echocardiography to guide different
percutaneous procedures such as patent foramen ovale (PFO)
closure, left atrial appendage and transcatheter aortic valve
implantation (TAVI). One of the advantages of ICE is that there
is no need for the use of general anaesthesia facilitating earlier
hospital discharge, and obtaining a superior imaging capability. 1, 2
The preferred treatment for severe symptomatic aortic valve
Figure A: CW Doppler ~ 5 m/s, 100mmHg
PA G E 23
Figure D: TAVI device positioning
Figure B: Heavily calcified aortic valve
reduced ultrasound catheter manipulation during the procedure
by a single operator was noted. RT3D ICE images of the
device attached to the delivery catheter immediately prior to
release (figure D) and following successful deployment
(figure1D) are shown.
Post procedure the patient recuperated successfully with
decreased gradients across the aorta and an improvement in
symptoms. In this case TAVI guided by ICE demonstrated that
the procedure could be done faster, requiring only local
anaesthesia and enabling an early hospital discharge.
Furthermore, due to the capabilities of real time monitoring,
less need for fluoroscopy and contrast agents.
Alejandro Rendon S, Imperial College London
Acknowledgments
Figure C: PLAX AO valve in 3D
stenosis is conventional aortic valve replacement. This involves
open-heart surgery to replace the narrowed valve with a new
artificial one. Transcatheter aortic valve implantation (TAVI) is
an alternative option for patients with severe aortic stenosis
(AS) who are classified as high-risk patients or patients not
eligible for conventional aortic valve surgery. Quality of life is a
critical measure of success for TAVI in this patient population.
Two major studies paved the way to the increasing clinical use
of TAVI. 3. 4
The first TAVI procedure in the UK, guided by ICE was done at
the Royal Manchester hospital. A 78 year old male patient with
severe aortic stenosis and breathlessness underwent a
transfemoral TAVI procedure (figure A and B demonstrating
CW Doppler and aortic valve by 2D AcuNav). A retrograde
system delivery was introduced through the femoral artery
allowing positioning of the prosthetic valve within the native
stenotic aortic valve. The procedure was guided using an
ACUSON AcuNav 3D ultrasound catheter (Siemens AG,
Germany). The AcuNav V catheter was inserted via a second
right femoral vein puncture providing real time three
dimensional monitoring. RT3D ICE (figure C) allowed
enhanced anatomical characterization of the narrow valve. A
PA G E 24
Dr Vaikom S Mahadevan, Simon A Hampshaw, and all the staff
at the Department of Cardiology, Manchester Heart Centre,
Manchester Royal Infirmary, Manchester, UK
References
1. Newton JD, Mitchell AR, Wilson N, et al. Intracardiac
echocardiography for patent foramen ovale closure:
justification of routine use. JACC. Cardiovasc Interv
2009;2:369; author reply 69–70.
2. Koenig P, Cao QL. Echocardiographic guidance of
transcatheter closure of atrial septal defects: is intracardiac
echocardiography better than transesophageal
echocardiography? Pediatr Cardiol 2005;26:135–9.
3. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic
valve implantation for aortic stenosis in patients who cannot
undergo surgery. N Engl J Med. 2010;363:1597–607.
http://dx.doi.org/10.1056/NEJMoa1008232.
4. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus
surgical aortic-valve replacement in high-risk patients. N Engl
J Med. 2011;364:2187–98.
http://dx.doi.org/10.1056/NEJMoa1103510.
4) Providing a Definitive
answer; the use of Definity
Transpulmonary contrast in
the diagnosis of aortic
dissection
Contrast CT, MRI and trans-oesophageal echocardiography
(TOE) have long been considered the gold standard for the
diagnosis of Type A aortic dissection, however, alternative
methods of diagnosis can sometimes be considered, especially
in the patient too unwell to be transferred to the CT scanner or
where there is a delay to intubation required to perform a transoesophageal echocardiogram. We report two cases where the
use of Definity trans-pulmonary contrast with bedside
transthoracic echocardiography (TTE) has led to a timely
diagnosis of this often catastrophic condition.
returned for a repeat echocardiogram 3 weeks later (Image B),
with the impression of a dissection flap. Definity contrast
injection confirmed the presence of a dissection flap, with
contrast entering the true lumen and then the false lumen via the
entry point of the dissection flap (Image C). A CT aortogram
confirmed the presence of a type A aortic dissection (Image D).
Case two
An 83 year old female with a past history of atrial fibrillation
and abdominal aortic aneurysm repair presented with abdominal
pain and collapse to the Emergency Department. Initial CT
Case one
A 68 year old male was admitted with chest pain and raised
inflammatory markers. An echocardiogram on admission
revealed a moderate pericardial effusion (Image A) without
clinical or echocardiographic evidence of cardiac tamponade.
A diagnosis of acute pericarditis was made and he was
discharged with a short course of colchicine with plans for
surveillance out-patient trans-thoracic echocardiography. An
unusual appearance of the ascending aorta was noted when he
Image C
Image A
Image D
abdomen revealed no overt intra-abdominal pathology, however,
a large pericardial effusion was noted (Image E) and an urgent
bedside TTE was performed. This confirmed a large pericardial
effusion with echocardiographic features of cardiac tamponade
including a fixed dilated inferior vena cava and diastolic
compression of the right ventricle. The pericardial fluid had a
homogenous echotexture suggestive of blood (Image F).
Modified parasternal aortic views visualising the ascending
aorta in short axis were suggestive but not diagnostic of aortic
dissection. The administration of Definity confirmed the
presence of a dissection flap in the proximal ascending aorta
(Image G).
Image B
Aortic dissection is a relatively rare cause of chest pain,
however, a missed diagnosis can have disastrous consequences
and early diagnosis can be life-saving. Acute aortic dissection
can be defined as a breach of the aortic intima leading to an
intimal flap and passage of blood down a true and false lumen
and usually occurs at a site of aneurysmal dilatation of the
PA G E 25
Image E
aorta. The dissection can spread from the site of the tear in an
antegrade or retrograde fashion. Aortic dissection is associated
with hypertension, dilatation of the aorta, collagen disorders (eg
Marfans and Ehlers-Danlos), vasculitis, trauma and bicuspid
aortic valve. It can be classified using the Stanford classification
system as Type A (involving the ascending aorta and/or the
aortic arch) or Type B (involving the descending aorta distal to
the left subclavian artery without involvement of the ascending
aorta). Patients presenting with type A dissection are often in
extremis and without urgent surgical intervention are unlikely to
survive. Type A dissection is frequently complicated by aortic
regurgitation, cardiac tamponade, myocardial ischaemia (most
commonly affecting the right coronary artery territory),
haemothorax and acute neurological deficit. Diagnosis is often
achieved by CT aortography (requiring the use of iodinated
contrast), magnetic resonance imaging or trans-oesophageal
echocardiography (requiring general anaesthetic). Patients can
be too unstable to be transferred to the CT scanner and although
near patient tests such as chest X-ray (widened mediastinum),
blood pressure differential between the arms and D-dimer blood
test can be helpful, none of these provide a definitive diagnosis.
The sensitivity for the diagnosis of aortic dissection by TTE is
poor (59.3%), mainly due to false positive findings in the
ascending aorta 1 and therefore although it is often considered
helpful in diagnosing the complications of dissection
(tamponade, regional wall motion abnormalities, aortic
regurgitation), it is not routinely used as a first line test for the
assessment of the aorta.
Transpulmonary contrast agents consist of microbubbles with
thin and relatively permeable shells filled with high-molecular
weight gas. The small size of the bubbles facilitates passage
from the venous to the arterial system. The ability of ultrasound
to detect these microbubbles relies on the unique non-linear
behaviour of the bubble in the echo field, undergoing resonant
oscillation in response to the variations in acoustic pressure
transmitted by the transducer2. Contrast enhancement has been
shown to be useful in transthoracic examinations when aortic
dissection is suspected and the intimal flap is difficult to
visualise or there is uncertainty in distinguishing a flap from an
artefact3. It can also be helpful in distinguishing the true and
false lumens. The true lumen is usually the smaller of the two
lumens which is pulsatile in systole and seen as the inner
contour on aortic arch views with evidence of systolic antegrade
flow on colour Doppler with no evidence of thrombus or slow
flow. Conversely, the false lumen is often larger with evidence
of systolic compression and reduced systolic antegrade flow on
colour Doppler. Thrombus can sometimes be identified in the
false lumen. From a technical perspective, it is important that
the view taken to acquire the images does not contain right
heart structures above the aorta (eg standard PLAX view) as the
contrast entering the right heart provides a ‘shadow’ on
structures below preventing accurate image acquisition. In our
experience therefore, the right parasternal and arch views are
generally the most helpful. A key component of the image
acquisition is the point at which the contrast influxes into the
aorta and passes through into the false lumen. It is therefore
important that a long loop is acquired at the time of first
contrast administration.
Image G
The cases detailed above serve as a useful reminder that transthoracic echocardiography with trans-pulmonary contrast can be
a useful ‘first line’ bedside investigation in patients with
suspected Type A dissection when CT aortography or TOE are
not immediately available.
Laura Dobson, Stuart Moir
Monashheart, Melbourne, Australia
References
1. Nienaber CA, von Kodolitsch Y, Nicolas V et al. The
diagnosis of thoracic aortic dissection by noninvasive imaging
procedures. N Engl J Med. 1993; 328 (1): 1-9
2. Mulvagh SL, Rakowski H, Vannan MA et al. American
Society of Echocardiography Consensus Statement on the
Clinical Applications of Ultrasonic Contrast Agents in
Echocardiography. J Am Soc Echocardiogr 2008; 21: 11791201
Image F
PA G E 26
3. Evangelista A, Avegliano G, Aguilar R et al. Impact of
contrast-enhanced echocardiography on the diagnostic
algorithm of acute aortic dissection. Eur Heart J 2010; 31:
471-479
CONFERENCE REPORT
BHVS Core Knowledge In Heart Valve Disease
The inaugural Core Knowledge in Valvular Heart Disease (VHD) Study Day was held in Guy’s Hospital, London on Monday
February 3rd. This educational initiative from the British Heart Valve Society (BHVS) is part of a range of educational activities
designed to promote wider recognition and understanding of VHD. The key objective of this day was to deliver the BHVS syllabus
on VHD, published recently by the BHVS and available online to all society members via the website. The concept of a Study Day
was clearly appealing, as all 70 places were sold out by mid-January. Attending delegates comprised a mix of echosonographers,
clinical scientists, cardiologists, GPs and cardiac nurse specialists.
The structure of the Core Knowledge Study Day involved lectures delivered by UK experts in the field, commencing with Dr Jo
D’Arcy (Oxford) who spoke on the changing epidemiology of VHD. The audience were reminded of the significant burden of VHD,
increasing due to an ageing population. Importantly, she also alluded to changing patient expectations as many of our older
population are fitter than in previous generations and thus more likely to expect intervention to restore their quality of life. Her talk
was followed by excellent lectures from the current and past Presidents of BHVS, Professors Simon Ray (Manchester) and John
Chambers (London) respectively, on aortic stenosis (AS) and aortic regurgitation (AR). Prof Ray highlighted several of thecurrent
challenges in AS assessment, including low-flow low-gradient (LFLG) AS with depressed EF but also with preserved EF, also
termed “paradoxical LFLG AS”. The pathophysiology of this condition was reviewed, as well as acknowledging that at present we
have very limited data on the natural history of this condition and thus also the optimal management strategy. Prof Chambers
discussed the causes of AR – including important causes of acute AR such as endocarditis, dissection and deceleration trauma – as
well as reviewing the echocardiographic findings in acute and chronic AR and indications for surgery. It was highlighted that up to
20% aortic valves may be eligible for repair rather than replacement, although at present data on long-term outcome of repair versus
replacement is scarce and there is limited surgical expertise with aortic repair in the UK also.
Dr John Klein (London), consultant microbiologist, then gave a very thorough seminar on infective endocarditis (IE). The audience
were reminded that incidence of Streptococcal endocarditis is falling whilst IE cases secondary to Staphylococcus species are on the
rise. The critical importance of blood cultures – preferably before antibiotic administration (!) – was emphasised. Contemporary
antibiotic protocols depending on organism were mentioned, as was a key South Korean randomised controlled trial (Kang et al
New Engl J Med 2012) suggesting that early surgery is superior to “conventionally-timed surgery” for improving outcome
(preventing embolic phenomena) in patients with large vegetations (>10mm length) with severe left-sided regurgitation.Dr Yassir
Javaid, a GPwSI in Cardiology, then delivered an insightful talk on community aspects of VHD, detailing the assessments that can
be made in primary care – including serial echocardiography – as well as sharing the model of valve clinic being developed between
primary & secondary care in Northampton. It was incredible to see the power of the GP databases and how far behind we are in
secondary care!
In the final talk before lunch, Dr Phil McCarthy (London) spoke on mitral stenosis (MS). Although the least common left-heart
valve lesion in Europe, it remains the dominant lesion in the developing world, in particular in sub-saharan Africa and the Indian
sub-continent. After reviewing the pathophysiology of acute rheumatic fever, the key features of chronic rheumatic heart disease of
the mitral valve – leaflet thickening, commissural fusion and chordal fibrosis / calcification – were discussed. Echocardiographic
assessment of lesion severity and suitability for balloon valvuloplasty were also covered, with mention of the low number of highvolume operators for valvuloplasty in the UK. He finished with a fascinating and unique case in which a patient at King’s Hospital
with a failing bioprosthetic mitral valve had undergone transvenous implantation of a TAVI device into the failing tissue MVR
across an ASD – with an excellent result. The ASD was, of course, also closed on the way out!
After lunch, Dr Anita MacNab (Manchester) gave a detailed overview of mitral regurgitation (MR), highlighting the differences
between primary (organic) and secondary (functional) MR, in terms of aetiology, echocardiographic assessment, management and
timing of surgery. The adverse prognostic impact of ischaemic MR was also discussed. Dr Cathy Head (London) then gave a
presentation on right heart valve disease, concentrating on tricuspid regurgitation in adult patients as well as highlighting the
prognostic importance of pulmonary regurgitation, especially in congenital heart disease patients.
Mr Chris Blauth, a London-based cardiac surgeon, then gave an interesting presentation on prosthetic heart valves. It is always
useful for non-surgeons to hear the thoughts of our surgical colleagues and thus a surgeon’s viewpoint on contemporary prosthetic
valves was indeed very helpful. For example, the choice of prosthesis was discussed at length, with a strong reminder that
contemporary bioprosthetic valves have an expected longevity considerably greater than the 10yr figure often quoted to patients, and
thus most patients >60yrs age would be offered tissue valves. The reasons for choice of bioprosthesis (e.g. stented vs. stentless) were
also briefly touched upon. Finally, Dr Saul Myerson (Oxford) gave an excellent closing talk on the role of multi-modality imaging in
VHD. He emphasised that cardiac MRI and CT should be used to complement echocardiography when echo alone is inadequate
(e.g. poor windows, sub-optimal alignment for Doppler interrogation etc).He demonstrated the utility of CMR for assessment in AS
patients as well as research led by himself in Oxford demonstrating the accuracy of quantitative CMR for assessment of AR,
showing that regurgitant fraction (<33% or >33%)accurately predicted onset of symptoms or (other reason for) referral for surgery.
He also discussed the ability of CMR to assess the mitral valve and provide accurate measurements of MR regurgitant fraction, as
well as accurate serial LV volumes and EF.
In conclusion, the first BHVS Core Knowledge in Valve Disease study day was, we hope, a successful event and we thank the day’s
delegates for their attendance and attention. Feedback forms will be closely analysed so that we may improve the event further and
BHVS plans to run this event on a regular basis. The event attracts both RCP CPD points as well as BSE re-accreditation points.
Please visit the BHVS website (www.bhvs.org.uk) for further details.
Dr Benoy N Shah Imaging Fellow, Southampton
PA G E 27
Echo in Africa 2014
By now we hope you have all heard about our humanitarian mission for 2014. A team of BSE volunteers will be travelling to Cape Town, South Africa to scan secondary school students for signs of
Rheumatic Heart Disease. This will be the first in a series of humanitarian screening camps that we
plan to run in collaboration with Tygerberg Hospital in Cape Town.
A dedicated, permanent scanning facility will be built with approximately 12 scanning stations on the
Tygerberg site. At the same time as performing the screening echo, volunteers will also be collecting data for research purposes.
The Children
Four schools in rural areas of Cape Town have signed up to take part in the screening project.
These students are from low socioeconomic communities – up to 90% of them live in shacks in
extreme poverty with little or no access to healthcare.
We won’t be able to scan all the students on this first visit – our target is 2,000. All students identified with RHD will be taken under the care of staff at the Tygerberg Hospital and receive appropriate
treatment and follow up.
Our volunteers
Following an electronic mailing in December 2013, many of you have already registered as potential
volunteers; thank you! Unfortunately our current indemnity and insurance policies mean that we will
only be able to accept volunteers who permanently reside in the UK and Ireland for this project,
however we will be looking into broader policies that will allow overseas members to participate in
future screening camps.
All selected volunteers will be required to find funding to cover their own flights and we’re working
with a UK based travel company who will be able to organise charity fares or flexible booking fares
for all travelling to Cape Town.
This is an excellent opportunity for our members to use their training and experience to make a positive contribution to communities in need.
How can you help?
There are logistical and operational costs that will need to be covered such as accommodation,
ground transportation, travel insurance, medical malpractice insurance and legal fees to name a few.
BSE is working hard to secure external funding to go towards covering these costs and reduce any
further fundraising burden on the volunteers.
Whether you are volunteering to take part in the humanitarian camp or not, you can still be part of
its success with a charitable donation. Annual subscription fees are due to be collected in April and
this would be an ideal time to make a small donation to help with this humanitarian project.
PA G E 28
Direct Debit
Members who pay their annual subscription by Direct Debit are invited to add a donation
amount and complete and return the authorisation form below. We will be able to make a
one-off collection from your account.
Standing order/Cheque
Members who pay by standing order or cheque can still complete and return the authorisation
below to authorise gift aid but you will need to make a one off adjustment to your payment
amount.
Online donations
If you make your payment online we are in the process of setting up an account with Virgin
Money Giving which you will be able to donate via.
Your support of this project is greatly appreciated. If you are a UK tax payer please
remember to read and tick the box for gift aid as we will be able to claim back from
the tax office an extra 25p in funding for each £1 you donate.
Please do donate whatever you can. Your donation WILL help to save a life.
If you need another gift aid form or know a non-member who would like to donate
please visit the BSE Website www.bsecho.org.
Please tick either of the first two boxes, remember to enter your donation amount. Please also tick
the third box so that we can claim gift aid.
My membership fee is currently collected by Direct Debit. In addition to my annual fee I wish to
make a one off donation of £_____ towards the 2014 British Society of Echocardiography Echo in
Africa project.
I currently pay my membership fee by standing order or cheque. In addition to my annual fee I
am donating £_____ towards the 2014 British Society of Echocardiography Echo in Africa
project.
Gift Aid: I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for
the current tax year (6 April to 5 April) that is at least equal to the amount of tax that all the charities
and Community Amateur Sports Clubs (CASCs) that I donate to will reclaim on my gifts for the current tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand
BSE will reclaim 25p of tax on every £1 that I have given.
Membership No.
Forename
House No/Name
Date
Surname
Postcode
Signature
PA G E 29
LETTER TO THE EDITOR
Introducing Echo Research and Practice – a new international journal, opening for submissions in March 2014.
Over recent months, the British Society of Echocardiography has been working with Bioscientifica – an international biomedical
publisher – to plan the launch of a major new journal for the echocardiography community. We’re delighted to announce that Echo
Research and Practice will open for submissions by the end of March.
Why is a new journal required? The field of echocardiography is rapidly expanding, and increasingly our work intersects with those
in associated disciplines and beyond. Echocardiography has become a multimodality technique in its own right with
subspecialisation in three-dimensional, transoesophageal, stress and interventional echocardiography. A lot of authors find it difficult
to publish their research due to the very limited number of journals dedicated to echocardiography. Open access publication offers
new ways to help communicate research discoveries more widely. The vision for our new journal is that it will draw from these two
opportunities to create a powerful new platform through which we can accelerate research, education and practice in
echocardiography for all disciplines that use the technique.
Echo Research and Practice will be the first open access journal in echocardiography. All articles will be free to read to a global
audience, with the journal funded by article publication charges (usually covered by the authors, their funder or institution). This
unrestricted access offers exciting opportunities for our community to forge new connections, and find innovative ways to improve
cardiovascular care.
Publication in Echo Research and Practice will be free for all articles submitted for publication in 2014. As you are a member of the
British Society for Echocardiography, I hope you will support this new initiative by submitting your best work, and becoming a
regular reader.
For more information on how to submit an article, and also to sign up to receive news on the first articles as they are published
online, visit: www.EchoResPract.com.
Professor Petros Nihoyannopoulos, Editor-in-Chief, Echo research and Practice
Fold on this line and place in a DL window envelope
BSE,
Docklands Business Centre,
10-16 Tiller Road,
London,
E14 8PX
PA G E 30
LIFETIME ACHIEVEMENT AWARD
Gill Wharton
At the last annual meeting in Liverpool I had the honour to present Gill with the BSE
Lifetime achievement award. As well as being my mentor and manager for 20 years
she is also a close personal friend of mine.
As a student echocardiographer starting my career in 1980 she taught me everything I
needed to know about echocardiography, congenital and acquired heart disease and
professionalism.
Gill has over 37 years experience as a sonographer, starting her career in 1976 at St
Georges Hospital London working with Graham Leech.
After this she worked briefly in Oslo as a research sonographer, before returning to
the UK to work for Smith Kline, teaching cardiac departments the emerging technique
of 2D and M mode.
It was during this time that she met Gordon Williams who was so impressed with her
that he went out of his way to secure her a job in his department. In 1980 she started
work as a research echocardiographer at Killingbeck Hospital in Leeds.
What makes Gill special as an echocardiographer is her passion for education and
research.
In the early 1980’s the field of echocardiography was a rapidly progressing field,
developing from 2D and M mode to new modalities of PW then CW Doppler
followed shortly by CFM.
Echocardiography was no longer just for the tertiary centres; DGH’s wanted the same
technology and their own departments. This meant clinicians and sonographers needed
to be taught and for many years Killingbeck delivered its annual Doppler courses. Gill
was an integral part of the faculty.
Her reputation as an expert and teacher was recognised and she was invited to teach
on the Salford BTEC echo course, which she did annually for over a decade.
At the same time her job at Killingbeck continued to grow she worked closely with
research registrars, teaching them echo and then assisting with their research projects.
Her enthusiasm for research has never faltered over the years and her up to date CV includes over 40 publications and abstracts.
In the early 1990’s she worked with the Leeds University to develop a Masters programme for medical ultrasound that was open to both radiographers and
cardiac physiologists. Up to this time only radiographers had been able to access formal academic teaching at Masters Level. Gill wrote, taught and
examined on the new programme.
In 2005 Gill became the 1st consultant sonographer in the country. As an expert in congenital heart disease she developed a small team of highly specialist
echocardiographers. She ran her own sonographer led fetal echo clinics for mothers with a family history of congenital heart diseases.
As part of her role as a consultant she developed and implemented a training programme for screening of the fetal heart. She travelled to obstetric
ultrasound departments across Yorkshire, Humberside and North Trent regions, where she trained the staff to image the fetal heart in multiple planes to
significantly increase the dection rates of congenital heart disease in unborn children.
Gill has been a part of BSE since the beginning; she has been an elected council member, a senior log book marker and a member of the Education
committee. She has more recently joined the departmental accreditation committee.
She was the lead author of the guidelines for chamber and valve quantification and a standard transthoracic study.
Many of you will have these guidelines on your echo room walls and will be impressed with the beautiful images used in the posters. Gill provided all these
and they are accurate examples of what she obtains on a day to day basis when scanning patients. She never cuts corners and always leads by example.
She represents BSE at the DOH and has been involved with MSC, developing the curriculum for STP. She protects the profession and strongly defends the
position that echocardiography should only be at scientist level.
In 2008 as recognition of her work within the field of echocardiography she was awarded the rare honour of the fellowship of the American society of
echocardiography.
Many of you will have been influenced by Gill in your day to day work. Whether you have worked directly with her in Leeds, or have been taught by her
on courses she has been involved with, or by use of the BSE guidelines I am sure Gill will have made a positive impact, and it is for this reason I
nominated Gill for the BSE life time achievement award.
Jane Allen, Vice President
We now invite nominations for 2014 award.
Can you think of someone you feel should be formerly recognised for their contribution to the field of Echocardiography?
Let us know who, and why they should receive the lifetime achievement award. All submitted nominations will be considered by
BSE Council.
Nominations must be sent to [email protected] by 27th June 2014.
PA G E 31
BSE Practical Competence Assessment Pilot
Available for all logbook submissions
Location: Wythenshawe Hospital, Manchester
Date: Sunday 1st June 2014
Time: 9am – 5pm. Candidates will be allocated a 2hr time slot in their confirmation letter
The BSE are modernising the current accreditation process and are looking for 50 candidates who would like to
participate in our pilot scheme.
This new practical assessment approach is designed to offer a more holistic approach to assessment. This pilot is aimed
at candidates who are ready to submit their Logbooks and digital cases and are happy to attend a BSE accreditation
examination day.
Each candidate will be required to rotate through a 3 station system where formal review assessment of each element of
accreditation would be completed.
Station 1
Presentation of logbook portfolio, as per the current BSE Accreditation Requirements. These will be reviewed by a nominated BSE
assessor.
If successful, the candidate proceeds to station 2. If unsuccessful then the candidate is offered constructive feedback and would be
welcomed to update their cases and submit through the current system.
Station 2
Candidates perform a normal echocardiogram as directed by the BSE assessor. This will be preformed on a volunteer and not a
patient.
If successful, the candidate proceeds to station 3. If unsuccessful then the candidate is offered constructive feedback and would be
welcomed to update their cases and submit through the current system.
Station 3
1-on-1 viva examination, this will require candidates to provide 5 specific digital cases as per the current BSE Accreditation
Requirements. A nominated BSE assessor will review a minimum of 1 of your 5 digital case submissions. The assessor will
randomly select the case/s for presentation and there will be an opportunity to discuss the digital cases with the nominated BSE
assessor.
Success at this station will result in candidates passing all stations and they will achieve immediate accreditation. This will
dramatically reduce the present time frame of 3 – 4 months.
If this sounds like something that you would like to be a part of this process, please register your interest with Kemi in the BSE
Accreditation Department by emailing [email protected]
The success of this pilot practical assessment will result in an improved and updated BSE accreditation process.
Please note, as this is a pilot to introduce a new process any individual who participates and is unsuccessful will not be penalised.
This pilot will not be deemed as a first submission attempt and as such this will not effect your future submissions. So in essence
this is a free attempt which may actually benefit the individual in the form of constructive feedback.
Please note, this information could be subject to change.
PA G E 32
BSE WORDSEARCH
Circle the words listed below in the
box at the bottom.
WORDS TO SEARCH FOR
ABCESS
ABLATION
AMYLOID
ANEURYSM
ANGIOGRAPHY
ANOMOLY
AORTA
ASYSTOLE
ARTIUM
BICUSPID
BIOPSY
BRADYCARDIA
CARDIAC
CARDIOVERSION
CAROTID
CELLULAR
CONSTRICTION
DEGREE
HAEMOCHROMATOSIS
HYPERTENSION
HYPOKINESIS
MECHANISM
MITRAL
MYXOMA
NASAL
REGURGITATION
RESTRICTION
SARCOIDOSIS
SINUS
TACHYCARDIA
TAMPONADE
TUTORIAL
VENTRICLE
Many thanks again to Stuart Self for the latest puzzle.
All correct entries will be put into a drawer to win £75 in vouchers.
We are still waiting on a Winner for the Scrambled Echo (Issue 84),
there is still time to re-submit
PA G E 33
RECENTLY ACCREDITED MEMBERS
Congratulations to the following members who have
recently achieved BSE Accreditation
Transthoracic Accreditation
Racquel Alicmas, Heatherwood and Wexham Park NHS Trust
Foundation
Cheryl Allardyce, NHS Ayrshire & Arran
Siobhan Armstrong, St George's Cardiac Investigations
Dr Sajid Aslam, University Hospital of Wales
Dr Graham Barker, John Radcliffe Hospital
Dr Anthony J Barron, Harefield Hospital
Mariam Chriszelle Batay, Queen Elizabeth Hospital
Sonia Batty, Royal Berkshire Hospital
Amanda L Beaumont, Calderdale and Huddersfield NHS Trust
Michael Bird
Sculeanu Bogdan, Newham Hospital
Stephen Browitt, Leeds General Infirmary
Dr Louise Brown, Southampton General Hospital
Mitzi Bulquiren, St Mary's Hospital, Paddington
Fiona Burchard, Royal United Hospital Bath
Maria Burnett
Howard Carter, Papworth Hospital
Cecil Castillo, Northwick Park Hospital
Victoria Cavanagh-Craig, County Durham and Darlington
NHS Trust
Joyce Krystel Cervantes, Basildon and Thurrock University
Hospital
Paul Charlton, Great Western Hospital
Dr Simon Claridge, Poole General Hospital
Margaret G Clarke, Great Western Hospital
Lindsay Coates-Bradshaw
Reuben Dane, Birmingham Heartlands Hospital
Jihan Despuez, Oxford University Hospitals NHS Trust
Nigel Dewey, Grantham & District Hospital
Dr Vijay Dhakshinamurthy, University Hospital of Coventry
Paul Edwards
Claire Elliott, Morriston Hospital
Richard Ewbank, James Cook University Hospital
Naomi Farnon, University Hospitals South Manchester
Eleanor Farrow, Norfolk and Norwich University Hospital
Catherine Fernandez, Musgrove Park Hospital
Cesar A Dos Santos Ferreira, Whipps Cross University
Hospital
Michelle Foster
Nadia Francisco, Hampshire Hospitals
Susan Geldard, Leeds General Infirmary
John Gierula, Leeds General Infirmary
Dr Mark Gilmore
Dr Christopher Gingles, Ninewells Hospital
Arioninson Pedro Gomes, Colchester General Hospital
Marcos Gonsalves, Buckinghamshire Healthcare
Charlotte Guanlao, Poole Hospital NHS Foundation Trust
Lindsey Hague, Doncaster Royal Infermary
Safia Hamid, Hammersmith Hospital
Dr Andrew Hamilton, South West Acute Hospital
Andrew Hancock, Northern General Hospital
Dr Alan Harkness, Colchester Hospital
Amanda Hayden, Worcester Royal Hospital
Erica Jane Henry, Macclesfield District General Hospital
Adam Hobbs, University Hospital Southampton
Dr Hasan Iqbal
Kim Isaac, Morriston Cardiac Centre
PA G E 34
Allison Jones
Carys Jones, Glangwili General Hospital
Lesley Jones, Warrington and Halton Hospitals NHS
Foundation Trust
Rachel Jones, Diana Princess of Wales Hospital
Faye Jowsey, Leeds General Infirmary
Sarah Justice, Tunbridge Wells Hospital
Satvinder Kahlon, Heart of England NHS Foundation Trust
Dr Hazlyna Kamaruddin
Dr Christina Kamperou, Russells Hall Hospital
Steven Kane, Broomfield Cardiac Department Chelmsford
Dr Afshin Khalatbari, Liverpool Heart and Chest Hospital
Dr T W Koh, London Chest Hospital
Dr Dipak Kotecha, University of Birmingham
Daniel Lamb, Essex Cardiothoracic Centre
Rebecca Leaning, New Cross Heart and Lung Centre
Dr Joanna C Lim, Hammermsith Hospital
David Lyth, Glan Clwyd Hospital
Rebecca Macrae, The Heart Hospital
Jayne Mahmoud, Lorn and Islands Hospital
Marvin Manicad, Basildon and Thurrock Hospitals
Julius Mas, Harefield Hospital
Andre Mason, Russells Hall Hospital, The Dudley Group NHS
Sheena Mathew, Addenbrook's NHS hospital
Thomas McConnell, Royal Victoria Hospital
Lukshmi McCormick, Northwick Park Hospital
Jennifer McKinven, Glenfield Hospital, University Hospitals of
Leicester
Bruno Mendes, King's College Hospital
Angela F Merrick, Norfolk & Norwich University Hospital
Sarah Moon, Cardiff and Vale University Local Healthboard
Emma Morgan, Addenbrooke's Hospital
Lisa Morgan, Cavan General Hospital
Asma Mullan, Queen Elizabeth Hospital, Birmingham
Dr Tarique Al Musa
Dr Govardhan Navaratnam, Nottingham City Hospital
Fria Marie Nitura, West Middlesex University Hospital NHS
Trust
Reina Noblesala, Queen's Hospital
Richard Nose, Basildon and Thurrock Hospital
Dr Bartosz Olechowski, Royal Bournemouth Hospital
Sevda Ozer, Royal Free NHS Trust
Maria Paton, Leeds General Infirmary
Sarah Ann Patterson, Morriston Hospital
Gemma Priest, New Cross Hospital
Nicole Purchase, Yeovil District Hospital
Dr Shouaib Qayyum, The Royal Wolverhampton NHS Trust
Dr Hindocha Rakhee, Royal Sussex County Hospital
Dr Krishnaraj Sinhji Rathod, King George Hospital
Dr Robin Ray, Royal Sussex County Hospital
Simon Reece, Good Hope Hospital
Emma Richardson, Portsmouth Hospitals NHS Trust
Jonathan Ritchie, University Hospital of North Durham
Laura Robinson, Sunderland Royal Hospital
Elaine Rogers
Jane Rogerson, Pinderfields Hospital
Lisa Romanis, Royal Infirmary of Edinburgh
Ian Rose, Gateshead Health
Harpreet Kaur Sahemey, Hammersmith Hospital
Dr Kulvinder Sandhu
Dr Anshuman Sengupta, Bradford Royal Infirmary
Emma Shannon, Manchester Royal Infirmary
Ben Sinclair, East Sussex Hospitals NHS Trust
Eswararaj Sivaraj, Southampton General Hospital
Konstantinos Sivridis, Charing Cross Hospital
Denise Skedd, New Victoria Hospital
Rebecca Stanhope, Ninewells Hospital
Christopher Stanton, The Royal Liverpool and Broadgreen
University Hospitals
Sally Stead, Salford Royal NHS Foundation Trust
Louise Stevenson, Sheffield Teaching Hospital
John Stewart, Sunderland Royal Hospital
Nigel Stokes, University Hospital of North Staffs
Dr Imran Sunderji, Castle Hill Hospital
Garry Sykes, Leeds General Infirmary
Dr Dewi Thomas, Royal Glamorgan Hospital
Charlotte Turner, Leeds General Infirmary
Dewet van der Westhuizen, Homerton Hospital
Gail Vokes, Nottingham University Hospitals NHS Trust
Eilish Walsh, Bon Secours Hospital, Cork
Dr Malgorzata Wamil, Milton Keynes Hospital
Dr Douglas Wan, Nottingham City Hospital
Celina M Warren
Natasha Watchorn, Mid Yorkshire Hospitals NHS Trust
Alison Weedall, Countess of Chester Hospital
Dr John Whitaker, University Hospital Lewisham
Dr John Whitaker, St Thomas' Hospital
Dr Aaron Wong, Morriston Hospital
Dr Kee Fui Wong, NHS Tayside
Dr Lisa Tze Mei Yung, Derriford Hospital
DATES FOR YOUR DIARY 2014
BSE members can also see up-to-date details via the
Events Calendar on the website www.bsecho.org
3rd & 4th April St George’s TOE Course
Location: London
Contact: [email protected] or
www.toe-courses.com
4th April BSE Spring Written Exams
Location: London, Belfast, Manchester,
Bridgend & Edinburgh
Contact: www.bsecho.org
5th April BSE/ICE Joint Meeting
Location: Hilton, Templepatrick
Contact: www.bsecho.org or 0207 345 5185
9th – 11th April Foundation Echocardiography
Location:
Contact: [email protected] or
www.midlandsecho.com or
fax 01782 801820
28th – 30th April Wythenshaw Introduction Of Echo Course
Location: Manchester
Contact: [email protected] or
0195 4200 018
12th – 15th May Ealing Hands On Course
Location: London
Contact: Shahla Kaleen or Claire Turner or
[email protected] or
[email protected]
13th May Manchester TOE
Simulation Workshop
Location: Manchester
Contact: [email protected]
Dr Juqian Zhang, Queen's Hospital
Transoesophageal Accreditation
Amor Mia Alvior, Queen Elizabeth Hospital, Birmingham
Dr Douglas Atkinson, Manchester Royal Infirmary
Dr Katrin Balkhausen, Oxford University Hospitals
Dr Ahmed Bashir, Walsall Manor Hospital
Dr Navtej Chahal, Royal Brompton Hospital
Dr Laura Dobson, MonashHeart: Heart Specialists and Heart
Care
Delfin Encarnacion, Barts Health Trust
Dr Christopher Hayes, Royal Bournemouth Hospital
Dr Yasmin Ismail, University Hospitals Bristol
Dr Afshin Khalatbari, Liverpool Heart and Chest Hospital
Dr Dipack Kotecha, University of Birmingham
Dr Jonathan Rosser, Sheffield Teaching Hospitals
Departmental Accreditation
Gold Standard Health LLP
Nottingham University Hospitals NHS Trust.
Russell Hall Hospital, Dudley
University Hospital Southampton
21st – 22nd May Core Knowledge
Location: Nottingham
Contact: www.bsecho.org
21st – 23rd May Third Milton Keynes Advance
Echocardiography Course
Location: Milton Keynes
Contact: [email protected]
24th June Manchester TOE
Simulator Workshop 2014
Location: Manchester
Contact: [email protected]
11th July Joint BSE & BHVS Meeting
Location: Kings College, London
Contact: www.bhvs.org.uk
16th – 18th July Foundation Echocardiography
Location: Stoke on Trent
Contact: [email protected] or
www.midlandsecho.com or
0178 2801 820
16th September Manchester TOE
Simulator Workshop
Location: Manchester
Contact: [email protected]
3rd – 4th October BSE Annual Clinical & Scientific
Meeting & Exhibition
Location: Birmingham
Contact: www.bsecho.org
Full details and course descriptions for all these courses are available
from the BSE website.
PA G E 35
CALL FOR ABSTRACTS 2014
We are pleased to announce that we are now accepting abstracts for the 2014 BSE Annual Meeting taking
place in Birmingham. The template for submission is available from the BSE website www.bsecho.org.Both
Technical and scientific submissions are welcomed.
For 2014 abstracts will be given as poster presentations only in the Exhibition hall on Friday 3rd October.
BSE members working in echocardiography who are participating in research are invited to submit Scientific
or Technical Abstracts summarizing their project. We are particularly keen to receive submissions from
echocardiographers or departments reflecting novel working practice, advances in echocardiographers or
interesting audits.
The following rules must be noted:
• More than one submission may be entered from a department, as long as there is a distinct difference
between each subject.
• All submissions will be judged by a panel of experts.
• The best submissions will be presented at the BSE Annual Conference on Friday 3rd October in Birmingham;
the lead Author of the submitted abstract must be available to present on that date. The Lead Author will
be asked to talk through their work live and then be available then to answer questions.
• Lead authors of submissions accepted for presentation will have their registration fee for the day of
presentation waived. Early bird fees will apply for Saturday 4th October if attending.
• The lead author will present the abstract for approximately 5 minutes followed by 5 minutes of audience
questions.
• The presentation will be judged by an expert panel.
• The winner will be invited to write a summary of their work for publication in ECHO, the journal of the BSE.
Abstracts are summaries of work and may contain elements of work that have been/will be submitted to
other international meetings (such as Euroecho) and other UK Meetings.
• Based on the overall score (written abstract submission plus oral presentation), the British Society of
Echocardiography investigator of the Year (2014) will be awarded.
The solution to the shortage of echocardiographers?
Both Mum, Clare Jackson and Dad
Justin Adams are members of the BSE.
This is their Son Samuel Adams, he picked up
the Echo Magazine while having his nappy
changed for a quick read.
PA G E 36
LEAD CARDIAC
PHYSIOLOGIST/DEPUTY
CARDIOLOGY MANAGER
We have a fantastic opportunity for a Lead Cardiac Physiologist/Deputy
Cardiology Manager to join the fantastic, friendly team at The Lister Hospital,
Chelsea. The post holder will provide specialist clinical knowledge and skills
across a broad range of cardiac physiological investigations and deliver
expert care for patients whilst supporting and developing more junior
members of the team to ensure consistently outstanding levels of patient
care.
As the Cardiology Manager is predominantly based at another facility, the
Lead Cardiac Physiologist will have the opportunity to lead the department in
a fairly autonomous nature whilst also assisting with various management
tasks, such as budgeting, auditing and developing the service provided.
The right person for this role will have extensive Cardiology experience, with
a BSc in Clinical Physiology (or equivalent) and be BSE accredited. They will
also be extremely patient focused with a desire to drive a consistently high
level of patient care, be flexible and adaptable and keen to share their skills
and knowledge with the team.
The Lister Hospital has an international reputation for providing high quality
private healthcare to patients across a wide range of specialties. For medical
professionals that value great training and career progression opportunities,
an open-door management policy and a real team spirit, it’s the career
destination of choice.
To apply please visit our website www.hcacareers.co.uk
You’re in goo d han ds
C A REER S AT HCA HOSPITA L S
Advanced Cardiac Physiologists in
Echocardiography
BSE Accredited Band 7+
Location: Oxfordshire (0.6 wte up to Full Time)
£44,000 per annum pro rata plus car allowance,
expenses and company pension.
Sessional Staff
Due to expansion in Community Services, we are
also looking for staff to join our team in the following
locations:Chertsey – Cobham – Leicester – Stoke
Echotech is at the forefront in the drive towards community based echocardiology services in the UK. We
are seeking suitably qualified Cardiac Physiologists to
work as part of our expanding team providing imaging and reporting in community based NHS sites.
Please apply in writing with a copy of your current CV to:
Jenny Tonkinson-Hoare – Clinical Operations Manager
[email protected]
SAVE THE DATE!
BSE Annual Meeting &
Exhibition 2014 will be held @
The International Convention
Centre, Birmingham
on 3rd & 4th October.
Registration will open soon.
A full provisional
programme will be placed
on the BSE website
www.bsecho.org
Closing Date: 1st May 2014
PA G E 37
•••• NEW FOR 2014 ••••
This year there will also be an option for hands on
training using simulators. Delegates will be allocated in
small groups to various centres across the UK within 3
months of the course (free of charge) for supervised
training on a simulator. This will be useful for those in the
early stages of echocardiography to improve their skills
and for experienced operators to understand 3D anatomy
using a computer model.
Core knowledge in
Echocardiography 2014
BSE points – Core Knowledge has now been awarded 6
points towards BSE re-accreditation (3 per day).
•••• NEW FOR 2014 ••••
Post Graduate Centre, Nottingham University Hospitals, City Campus
Wednesday 21st and Thursday 22nd May 2014
Course fee £250
This is a 2 day course covering core topics in adult echocardiography. Course
Cours
ursee content
conte
ntent will be
be delivered
de
by experts in the field of echocardiography and will cover the core knowledge
wledge aand
nd curre
current
rrent recommendations for assessment of various conditions. In addition to didactic lectures,
lectures
lectu
res, there
re will be interactive
case discussions on various topics with tips and tricks for assessment. You will have the opportunity
to test your knowledge and improve confidence using self marking theory and video questions.
The course is aimed at anyone starting out in echocardiography or those wishing to refresh their
knowledge. The course covers the majority of the syllabus for echocardiography accreditation
examination and is ideal for those wishing to sit the BSE exam in the next 6-12 months.
Topics covered Normal views and minimum data set
Practical physics and image optimisation (how to make the best use of the ultrasound machine)
Ischaemic heart disease and LV function – principals and methods of assessment;
Right heart assessment including tricuspid and pulmonary valve
Aortic valve disease
Mitral valve disease
Approach to adult congenital heart disease (CHD)
Cardiomyopathies
Echo in emergency medicine
Prosthetic valves
Reporting a transthoracic study
Cardiac masses and endocarditis
Hemodynamic assessment
Course fee includes handouts, refreshments and lunch. Local accommodation details available on request.
Feedback from September 2013
“Very useful and well run course. Good variety of topics covered - useful for refresher with measurements etc and very
useful for things that are not commonly done in every case.”
“Very in-depth course covering a vast array of topics. Thoroughly enjoyed all lectures and look forward to putting all I have
learnt over the last 2 days into practice. Many thanks.”
“Excellent course”
To register please go to www.bsecho.org For further details including session
extracts please go to www.bsecho.org/events-courses/core-knowledge/
BSE members will need to register online.
PA G E 38
Non members will be able to print off a paper registration form.
Advanced Imaging Day 7
9th May 2014
Royal Society of Medicine, London
Advanced Imaging in Hypertrophic Cardiomyopathy
Sessions will include anatomy, diagnosis, the roles of multimodality imaging and pitfalls.
Presenters will include anatomists, surgeons and interventionists.
The day is suitable to all involved in the care of patients with Hypertrophic Cardiomyopathy,
since it offers a holistic approach to their care with a focus on imaging such hearts.
5 BSE reaccreditation points have been allocated to this meeting and
CPD points have been applied for.
For further details and to register please go to
www.bsecho.org/events-courses/advanced-imaging-2014/
COMMUNICATING WITH THE SOCIETY
Dawn Appleby [email protected] - 020 7345 5185
BSE, Docklands Business Centre, 10-16 Tiller Road, London, E14 8PX
Tel: 020 7345 5185
Fax: 020 7345 5186
We can also be contact via email to:
General and Post Accreditation (membership, re-accreditation, Distance Learning)
Chris Grant at [email protected]
Accreditation (exams, logbook submissions) – Kemi Olanrewaju at [email protected]
Financial matters (payments, direct debits, duplicate receipts) – Ingrid Daniel at [email protected]
Meetings and Events – Dawn Appleby at [email protected] [email protected] - 020 7345 5185
For submission of educational articles or case reports for ECHO:
Dr. Gordon Williams at [email protected] and/or [email protected]
PA G E 39
Irish Cardiac Echo
& Imaging Group
I.C.E.
Joint BSE & ICE Meeting
Saturday 5th April 2014
Hilton Templepatrick, Belfast
This one day meeting will be held the day following the BSE spring accreditation
exams taking place at the same location in Belfast.
Provisional Programme (subject to amendment)
• Surveillance of aortic regurgitation – just the LV?
• Is low gradient low flow just moderate AS?
• Defining ischaemic MR on echocardiography
• A systematic approach to ACHD on TTE
• Ventricular Septal Defects
• Is TR enough in pulmonary hypertension?
• Echo in CRT – dead as a dodo?
• Stress and Perfusion – now required reading
• Echo assessment of the RV – still a step too far?
• DICE Cases: The Weird and the Wonderful
The day has been approved for 5 BSE re-accreditation points.
CPD points have been applied for
To register to attend please go to
www.bsecho.org/events-courses/bseice-meeting-2014/
The pre-registration fee is £65 per person.
All registrations will be processed in GB£.
Onsite accommodation is available.
PA G E 40

BSE/ ICE Joint Meeting Saturday 14 March 2015 Royal College of

KSE Case Conference 座長 Jae-Kwan Song (University of Ulsan

The Quadricuspid Aortic Valve

Expanded Series C Financing Round

Ratio Relay Valve

1stState of the art and Challenges of Research

Post-Market JUPITER Registry at EuroPCR 2014

EQUITY WEEKLY REPORT

( Hoya Corporation ).

Insertion Flow Meter Device (IFM)