Echo Research and Practice最新文献

The increasing demand for adult congenital heart disease (ACHD) services requires innovative solutions to reduce waiting times and optimise patient care. This paper presents the implementation and development of an ACHD Scientist-led clinic at Guy's and St Thomas' NHS Foundation Trust, providing an alternative, cost-effective, and efficient service model. A comprehensive service audit identified challenges related to patient backlogs, clinic efficiency, and administrative coordination. Subsequent restructuring efforts, including an expanded appointment system, improved referral pathways, and enhanced clinical governance, led to a significant reduction in overdue appointments from 15% to 2%, despite an overall increase in patient numbers. Comparative cost analysis demonstrated that the Clinical Scientist-led model is more cost-effective than the traditional models. Additionally, patient satisfaction surveys and Consultant evaluations confirmed this model's high quality and safety. These findings highlight the potential for broader adoption of Clinical Scientist-led clinics within the ACHD networks to improve accessibility, efficiency, and sustainability of care.

Background: Rheumatic mitral stenosis (MS) is characterised by structural alterations that reduce the size of the valvular orifice. In addition, changes in valve geometry may have haemodynamic consequences that extend beyond the narrowed orifice, influencing the overall clinical presentation of MS. The aim of this study was to develop an index to assess the haemodynamic severity of the stenosis.

Methods: A total of 186 patients with rheumatic MS who underwent comprehensive three-dimensional (3D) transoesophageal echocardiographic assessment were included. Dedicated software was used to extract a range of morphological variables to evaluate mitral valve geometry, including diameter, area, height, volume, and the aortic-mitral angle. To quantify the volume enclosed within the stenotic structure, we developed the 3D Doming Index (DI), calculated by dividing the valvular volume (tenting volume) by the theoretical volume of a cylinder generated by the mitral annulus and valvular height (tenting height). Linear regression models were employed to identify determinants of the mean pressure gradient.

Results: The 3D Doming Index demonstrated a significant association with the transmitral pressure gradient in the multivariate model, after adjusting for confounders including age, sex, heart rate, pulmonary artery systolic pressure, net atrioventricular compliance (C_n), and left atrial volume. Incorporation of the 3D Doming Index into the model improved overall performance.

Conclusions: The geometric configuration of the mitral valve contributes to the haemodynamic burden of obstruction in rheumatic MS. The 3D Doming Index offers valuable insight into the relationship between valve anatomy and the resultant haemodynamic impact of the stenosis.

Introduction: Accurate chamber quantification in transthoracic echocardiography (TTE) is important for guiding clinical decision-making. We aimed to assess the accuracy and reliability of patients' self-reported height and weight compared to measured height and weight, and how any differences in the calculated body surface area (BSA) may affect TTE parameter classification.

Methods: Consecutive patients attending for out-patient TTE were prospectively recruited at a large NHS Trust as part of a service evaluation. Height and weight were initially self-reported and then measured. TTE parameters were subsequently indexed to BSA or height based on both self-reported and measured values and compared.

Results: 698 patients participated. Self-reported and measured height, weight, and BSA were strongly correlated (r > 0.90). There was a difference between the mean self-reported and measured height (self-reported being 1.1 cm higher, p < 0.001) and weight (self-reported being 1.6 kg lower, p < 0.001) as well as the resulting BSA (self-reported being 0.01m² lower, p = 0.008). Indexing TTE parameters to self-reported (rather than measured) values resulted in changes to the indexed left ventricular end-diastolic volume, left ventricular end-systolic volume, Sinuses of Valsalva diameter and proximal ascending aorta diameter (all p < 0.05), although the effect sizes were small.

Conclusion: Compared to measured height, weight and calculated BSA, self-reported values are statistically different but result in little clinically important change to TTE parameters in out-patients attending for TTE. However, given the possible impact on clinical decision-making, TTE conclusions based on self-reported height and weight should be interpreted with care, particularly indexed left ventricular volumes and aorta dimensions. Echocardiographers should be vigilant in identifying rare cases where individuals significantly misreport their height or weight.

Background: Left ventricular thrombus (LVT) is a recognized complication of severe left ventricular (LV) systolic dysfunction. While cardiac magnetic resonance (CMR) Imaging is considered the gold standard due to its high sensitivity and specificity for detecting LVT, its availability remains limited in Sub-Saharan Africa. In contrast, 2D transthoracic echocardiography (TTE) is more accessible and commonly used in clinical practice. This study aimed to determine the incidence of LVT in patients with a left ventricular ejection fraction (LVEF) of less than 35% from any etiology, and to compare the diagnostic accuracy of TTE against CMR for its detection.

Methods: This prospective, cross-sectional study was conducted at the Aga Khan University Hospital Nairobi (AKUH, N). The study included patients aged 18 years and above with new onset heart failure symptoms and severely reduced LVEF of ≤ 35%. The study was conducted between January 2021 and December 2023. Patients underwent non-contrast 2D TTE and CMR within a 14-day interval. Diagnostic accuracy of 2D TTE was assessed using sensitivity, specificity, and predictive values.

Results: A total of 100 patients were included in the final analysis. The median age of participants was 58.0 years (IQR: 47.0-67.0). The median LVEF was 30% (IQR: 20-33). The median time between 2D echocardiography and cardiac MRI was 10 days (IQR: 1-12). LVT was detected in 11 patients (11%) on CMR. A significantly higher proportion of those with LVT had an ischemic etiology (n = 10, 90.9%) (p < 0.05). Participants with LVT had a lower LVEF (19%, IQR: 14-31) and larger left ventricular internal diameters (IQR 62 mm, IQR: 55-77.5) (p- value < 0.05). Among those with LVT, 73% (n = 8) had it detected by both diagnostic modalities. The 2D TTE's sensitivity and specificity for detecting LVT were 0.72 and 0.78, respectively, with an excellent negative predictive value of 0.98.

Conclusion: 11% of patients were found to have LVT on CMR. Patients with ischemic cardiomyopathy, significantly reduced LVEF, and a dilated LV, were identified as being at the highest risk for developing LVT. 2D TTE showed an excellent negative predictive value in excluding the presence of LVT.

Background: In this study, we evaluated the utility of the continuous wave (CW) Doppler pre-attenuation velocity envelope as a potential surrogate for pulsed-wave (PW) Doppler-based interrogation of left ventricular outflow tract (LVOT) flow in patients with moderate or severe aortic stenosis.

Methods: In a retrospective analysis, we examined 92 patients with moderate or severe aortic stenosis. Pulsed-wave Doppler was employed to acquire LVOT velocity and velocity time integral (VTI) in the 5-chamber view. CW Doppler recordings were scrutinized across multiple views with a specific focus on identifying a discernible pre-attenuation velocity envelope. Through manual tracing, we extracted peak velocity and VTI across the aortic valve as well as the pre attenuated velocity, which was used as a surrogate for LVOT assessment and substitute in the continuity equation in the evaluation of aortic valve stenosis.

Results: The pre-attenuation velocity envelope was distinctly discernible in 83 (90%) of patients. PW Doppler of the LVOT velocity significantly correlated with pre-attenuation velocity from the 5-chamber view (r = 0.75, p-value < 0.001) but showed a weaker correlation when obtained from other windows (r = 0.46, p-value < 0.001). Bland-Altman analyses indicated high levels of agreement between pre-attenuation velocities from the 5-chamber view and PW Doppler derived LVOT velocities, while weaker levels of agreement were observed between pre-attenuation velocities from other windows and PW Doppler derived LVOT velocities.

Conclusions: The pre-attenuation velocity envelope is attainable in the majority of patients with aortic stenosis. The pre-attenuation velocity envelope recorded from the 5-chamber view exhibits a noteworthy correlation and agreement with PW Doppler LVOT velocity. This observation positions pre-attenuation velocity envelope as a promising alternative and plausibility check for hemodynamic assessment in patients with aortic stenosis.

Background: Stress echocardiography is a key imaging modality for assessing coronary artery disease in the UK. Traditionally, stress echo services were led by consultant cardiologists, but evolving workforce models have increased the involvement of cardiac physiologists and scientists. This study, as part of the National Review of Stress Echocardiography Practice (BSE N-STEP), aimed to evaluate current stress echo workforce structures and test outcomes across a group of UK hospitals to inform future workforce planning.

Results: Data were analysed from 8506 stress echocardiograms, conducted between September 2020 and June 2023 across 34 UK hospitals. Based on the supervising workforce, stress echocardiograms were allocated into either a doctor-led (DL) or cardiac physiologist/scientist and nurse-led (CNL) model. 56.9% of stress echocardiograms were DL, while 42.7% were conducted under a CNL model. Physiologists/scientists were the most frequently involved staff (81.9%). The primary indication for stress echocardiography was ischaemia evaluation (89.4%). Dobutamine stress echocardiography was more common in DL services (63.0 vs. 56.3%, p < 0.001), while CNL services performed more exercise stress echocardiography (42.8 vs. 36.4%, p < 0.001). Test positivity rates were similar between DL and CNL models (17.1 vs. 17.7%, p = ns), though the CNL group had a lower complication rate (2.2 vs. 5.3%, p < 0.001). Reporting of stress echocardiograms remained consultant-led in 82% of cases, but physiologist/scientist-led reporting showed an increase over time. Training was primarily provided to registrars/fellows (60.2%), with physiologist/scientist trainees accounting for 32.4%.

Conclusions: This study provides a contemporary overview of stress echocardiography workforce models in the UK, highlighting the increasing role of cardiac physiologists and scientists in supervising and reporting stress echocardiography. Despite these shifts, consultant cardiologists remain central to stress echo reporting. The findings support the integration of multidisciplinary workforce models to enhance service efficiency. These insights will aid in future workforce planning and training strategies to optimise stress echocardiography service provision across the NHS.

Background: Myocardial strain measurements are increasingly used in research and clinical practice. However, there are limited data on inter-modality agreement and reproducibility. We aimed to investigate the inter-technique agreement of transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR) imaging derived left atrial (LA) and left ventricular (LV) deformation parameters.

Methods: Subjects with or without cardiovascular disease were prospectively recruited and had TTE and CMR on the same day. Ten subjects with type 2 diabetes (T2D) had both scans repeated within two weeks for test-retest reproducibility assessment. Myocardial deformation analyses were undertaken including LA strain (LAS) corresponding to LA reservoir, conduit and booster pump phases, LV global longitudinal strain (GLS) and peak early/late diastolic strain rate (PE/PLDSR) and LV mid-circumferential strain (Mid-CS) and strain rates.

Results: 222 participants (T2D (n = 87); severe aortic stenosis (n = 78) and healthy volunteers (n = 57)) were included. There were no significant differences between TTE and CMR measured LAS parameters, with moderate agreement between imaging modalities (ICC = 0.55-0.69). LV parameters were significantly higher on CMR except for Mid-CS which was higher on TTE (-19.3 ± 3.19 vs. -23.0 ± 4.37; p < 0.001). Inter-technique agreement was poor for all LV deformation parameters, except PLDSR with modest agreement (ICC = 0.52-0.66). CMR test-retest reproducibility was good to excellent for LAS and LV strain rate parameters (ICC = 0.73-0.90). TTE test-retest reproducibility was good for conduit LAS and LV_PEDSR (ICC = 0.80).

Conclusion: There is modest agreement between TTE and CMR for LAS and poor agreement for LV strain assessment, suggesting that these techniques cannot be used inter-changeably. In a small subset of participants CMR test-retest reproducibility was overall better than TTE.

Background: Aortic stenosis (AS) is a common valvular heart disease where aortic valve replacement (AVR) is the only treatment. A novel staging system based on cardiac damage was developed to assess the pathophysiological consequence of AS and this has been shown to be associated with outcomes post AVR.

Methods: We conducted a systematic review of studies which evaluated cardiac damage in patients with AS. A search of MEDLINE and EMBASE was performed with data being extracted from relevant studies. The main outcome of interest were proportion of AS patients with signs of cardiac damage, all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events.

Results: A total of 18 studies were included with 21,876 patients (mean age 79 years, 52.7% males). Pooled analysis indicated 76% of symptomatic severe AS patients and 88% of asymptomatic moderate/severe AS patients had signs of cardiac damage, with stage two being the most commonly reported (25.1% and 32.3% respectively). For symptomatic severe AS patients, the pooled all-cause mortality and cardiovascular mortality rates increased along an increase in cardiac damage stage from 9.4% to 2.0% respectively for stage 0 to 24.2% and 36.1% respectively for stage 4. In patients with asymptomatic moderate / severe AS, all-cause mortality ranged from 30.0% in stage 0 to 51.2% in stage 3/4. In patients with symptomatic severe AS undergoing AVR, meta-analysis indicated an increase in odds of cardiovascular related mortality for stage 4 cardiac damage only (OR 6.89, 95% CI: 3.04,15.61, p = 0.003). An increased odds of all-cause mortality was seen in for cardiac damage stages 1, 3 and 4 (OR 1.4, 95%CI: 1.10,1.77, p = 0.01, OR 2.27, 95%CI: 1.76,2.92, p = 0.0002 and OR 2.94, 95%CI: 1.97,4.38, p = 0.0006 respectively).

Conclusions: Cardiac damage is a common finding amongst patients with AS irrespective of AS severity or symptomatic status. Mortality rates appear to increase alongside an increase in cardiac damage staging. Cardiac damage may provide prognostic valve when considering the timing of AVR with left ventricular and right ventricular abnormalities being associated with increased odds of mortality.

Clinical trial number: Not applicable.