The CardioPhiles

Diastolic Assessment Standards

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New business:

1. Stress echo protocol.

2. Standartization of adult echo template. “Edit list"

3. Call in policy.

4. 3-D Dataset - Volumetric 3-D LVEF and Global longitudinal strain. Mckesson is validating phase of LVA 3.1, once validated we’ll be upgraded and volumes and LVEF are improved - Doug Vito TomTech. Chemotherapy protocol.

5. Old echo’s for comparison. Print reports not available on McKesson (Xcellera and outside hospital). No need to print this already available in the system.

6. Office - Discussion about entering number in paperwork. Need prosthetic valve details.

 

Stress echocardiography Protocol

1. Basic Protocol - Prototype ischemia detection/CP.

     a. REST-MORPHOLOGY/FCN: PLAX with and w/o color - Assess LV size and wall thickness, MV & AV disease, Aortic root

     b. REST-MORPHOLOGY/FCN: PLAX TR inflow view color and RVSP

     c. REST-MORPHOLOGY/FCN: 4chamber with and w/o color, RVSP

     d. REST-WALL MOTION: A4ch, A2ch. A3ch, PSAX, PLAX

     e. Post-stress: A4ch, A2ch. A3ch, PSAX, PLAX

2. Diastolic Assessment - If dyspnea based on indication or questioning.

3. Mitral stenosis - Mean grad MV & RVSP, rest and post-exercise.

4. Low gradient low LVEF Aortic stenosis. Rest LVOT diam. LVOT PW, AV CW, SV rest and Dobuta so that AVA/DVI/Cardiac reserve can be calculated.

5. Contrast utilization. Data from Literature:

 

BSE stress echocardiography. Heart 2004;90:vi23-vi30

- If image quality is suboptimal—for example, endocardial borders are barely or not visible in two or more myocardial segments—application of ultrasound contrast agents should be considered or the patient should be referred for another imaging test like myocardial scintigraphy or MRI.- Multiple views have to be recorded to ensure visualisation of left ventricular segments supplied by each of the three major coronary distributions. Four views are usually sufficient (apical four chamber and two chamber views, parasternal short axis and long axis or apical long axis). When using contrast, both baseline and stress images should be enhanced. The frame rate should be at least 25 frames per second. However with heart rate > 140 beats/min, acquisition may be enhanced with frame rates > 30 frames per second. The number of frames captured can vary from eight per cardiac cycle, which captures only systole, to >25 frames to capture of the entire cardiac. No clinical advantage to either scheme has been demonstrated. - Systematic review recommended, starting with assessment of the image quality. Endocardial border definition can be used as an indicator of image quality. Image quality is graded as good, acceptable, or poor and non-diagnostic segments are identified. Analysis of DTI recordings may supplement interpretation. - The BSE Policy Committee recommends that physicians interpret a minimum of 10 SE per month to maintain interpretational skills. It is recommended that sonographers perform a minimum of 10 SE per month to maintain an appropriate level of skill.

 

ASE Guidelines JASE Sept 2007.

- Tissue harmonic imaging should be used for stress echocardiography imaging. This reduces near-field artifact, improves resolution, enhances myocardial signals, and is superior to fundamental imaging for endocardial border visualization.- Contrast should be used when two or more segments are not well visualized.- The baseline echocardiogram ... should include a screening assessment of ventricular function, chamber sizes, wall-motion thicknesses, aortic root, and valves unless this assessment has already been performed.- To maintain competence, it is recommended that physicians interpret a minimum of 100 SE per year, in addition to participation in relevant CME. It is recommended that sonographers perform a minimum of 100 SE per year to maintain an appropriate level of skill.- Dyspnea - Doppler assessment of the mitral inflow velocities should be assessed at rest, during exercise, and in recovery when the E and A velocities are no longer fused. Doppler recordings should be acquired at a sweep speed of 100 mm/s. The E/e’ ratio can be used to estimate LV filling pressures at rest and exercise. Healthy individuals will show a similar increase in mitral E and annular e’, such that the ratio has no or only minimal change with exercise. Patients with impaired LV relaxation develop an increase in LV filling pressures with exercise as a result of tachycardia and the abbreviated diastolic filling period. Accordingly, mitral peak E velocity increases. However, given the minimal effect of preload on annular e’ in the presence of impaired relaxation, annular e’ remains reduced. Therefore, E/e’ ratio increases with exercise in patients with diastolic dysfunction. Validated against invasive measurements.- MS - In sedentary patients, exercise-induced dyspnea, along with an increase in mean transmitral pressure gradient to >15 mm Hg and PASP >60 mm Hg, identifies patients with hemodynamically significant lesions that may benefit from percutaneous valvotomy if anatomy is suitable and MR is mild or less. When exercise results in only minimal changes in transmitral pressure gradient but a marked increase in PASP occurs, further evaluation for underlying lung disease is indicated. In patients unable to exercise, dobutamine stress may be used. - LV systolic dysfunction and low-gradient aortic stenosis, defined as Doppler-derived aortic valve area less than 1.0 cm2 and mean gradient <30 mm Hg. In these patients, dobutamine is used to assess both the severity of AS and the presence of LV contractile reserve. The infusion begins at 5 mcg/ kg/min and is increased at 5-minute intervals to 10 and 20 mg/kg/min. European Association of Echocardiography. Stress echocardiography expert consensus statement. Eur J Echocardiogr (2008) 9 (4):415-437. - In the ischaemic response, a segment worsens its function during stress from normokinesis to hypokinesis, akinesis, or dyskinesis (usually at least two adjacent segments for test positivity are required). - An ischaemic response may occasionally occur late, after cessation of drug infusion. Tsoukas A, Ikonomidis I, Cokkinos P, Nihoyannopoulos P. Significance of persistent left ventricular dysfunction during recovery after dobutamine stress echocardiography. J Am Coll Cardiol 1997;30:621-6.

 

EAE/ASE European Journal of Echocardiography (2009) 10, 165–193

- However, the paucity of clinical data and the potential limitations in patients with regional LV dysfunction, mitral valve disease, and atrial fibrillation pre- clude recommendations for its routine clinical use at this time.

 

Stress Doppler Echocardiography in Relatives of Patients With Idiopathic and Familial Pulmonary Arterial Hypertension. Ekkehard Grünig, et al. Circulation. 2009; 119: 1747-1757

Feasibility of using stress Doppler echocardiography for this indication has not been assessed. No confirmed consensus exists as to which PASP threshold is diagnostically relevant for exercise-induced PH, particularly if stress echocardiography is applied. A high threshold would increase specificity but decrease sensitivity.12 Only a few invasive and noninvasive studies have analyzed the normal values for pulmonary artery pressures during exercise and prolonged hypoxia. Gurtner et al13 and Janosi et al14 showed that in healthy subjects the systolic pressures do not exceed 40 mm Hg even during heavy exercise. Bossone et al15 found higher values in athletes as a consequence of increased flow and left atrial pressure. Nevertheless, even in athletes, PASP did not exceed 40 mm Hg until high workloads (>160 W) had been reached. The cutoff TRV value of 3.08 m/s (corresponding to 43 mm Hg PASP) defined in this study and separating NR from HR subjects was determined by measurements in a large number of healthy control subjects; 3.08 m/s was identical to the value obtained by density analysis and close to the mean peak value plus 1 SD (3.06-m/s TRV=42.4-mm Hg PASP). Furthermore, this threshold is very consistent with previous invasive30 and noninvasive15,31,32 studies that demonstrated mild increases in pulmonary arterial pressure with exercise in a normal population. However, this cutoff level might not be adequate in subjects with >60 years of age or at higher workloads (>150 W) and for athletes, TRV and PASP can exceed 3.08 m/s and 43 mm Hg, respectively.15 We used a fixed right atrial pressure estimate of 5 mm Hg if the inferior vena cava was <20 mm. Normal values of Doppler-derived systolic PAP during exercise have consistently been reported to be , 40– 45 mmHg. Jean-Luc Vachie ́ry. European Heart Journal Supplements (2007) 9 (Supplement H), H48–H53.Strain - J Am Coll Cardiol 2014;Apr 2:[Epub ahead of print].- Cardiotoxicity from cancer therapy is a leading cause of morbidity and mortality in cancer survivors, and is most typically defined as a decrease in left ventricular ejection fraction (LVEF) by ≥5% or ≥10% for symptomatic and asymptomatic patients, respectively (from baseline to a LVEF <55%). As early identification may alter management and attenuate cardiotoxicity, there is a need for early markers of cardiotoxicity before a significant change in EF occurs. - Using two-dimensional strain imaging, global longitudinal strain is more reproducible than other measures of strain.- On a review of the literature examining the prognostic value of strain imaging in chemotherapy patients, an early decrease of 10-11% (95% confidence interval, 8-15%) in global longitudinal strain predicts cardiotoxicity. Other individual markers have not been predictive, although combined use of global longitudinal strain and LV twist may be a better predictor than the former variable alone. - While normal ranges for global longitudinal strain from a recent meta-analysis suggest a normal cutoff of -19% to -22%, there is significant between-patient variability, suggesting that within-patient changes in strain may be more reliable than population-based thresholds. - further multicenter study is needed.