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Cardiovascular stress testing remains the mainstay of provocative evaluation for patients with known or suspected coronary artery disease. Stress echocardiography has become a valuable means of cardiovascular stress testing. It plays a crucial role in the initial detection of coronary disease, in determining prognosis, and in therapeutic decision making. The purpose of this document is to outline the recommended methodology for stress echocardiography with respect to personnel and equipment as well as the clinical use of this recently developed technique. Specific limitations will also be discussed.
Over the past few years, the clinical use of echocardiography has continued to expand. Echocardiographic techniques are used widely to define normal and abnormal cardiac anatomy, evaluate cardiac chamber sizes and dynamics, assess valvular and pericardial diseases, detect intracavitary masses, measure pressure gradients across discrete stenoses, determine flow volumes, detect and assess the severity of valvular regurgitation, demonstrate and quantitate intracardiac shunts, and measure the timing of cardiac events. These and related applications have led to the increasing use of echocardiography in the diagnostic evaluation of many cardiac disorders. Echocardiography requires considerable theoretical knowledge, technical skill and practical experience to be used in an optimal manner. Previous publications have suggested guidelines for physician training in the techniques of M-mode and 2-dimensional echocardiography. The clinical applications of echocardiography continue to grow, however, and Doppler techniques for evaluating blood flow have become an established component of the echocardiographic evaluation of many disorders. This article presents the current recommendations of the American Society of Echocardiography as to the background knowledge, the nature and amount of practical experience, and the type of training site that are optimal for the training of physicians who take responsibility for the conduct and interpretation of echocardiographic studies.
OBJECTIVES: This study was designed to test the feasibility and efficacy of using real-time three-dimensional echocardiography (RT-3D) to detect ischemia during dobutamine-induced stress (DSE) and compares the results with conventional two-dimensional echocardiography (2D). BACKGROUND: Real-time three-dimensional echocardiography, a novel imaging technique, offers rapid acquisition with multiple simultaneous views of the left ventricle (LV). These features make it attractive for application during stress. METHODS: Of 279 consecutive patients screened for image quality by 2D, 253 patients with adequate images underwent RT-3D and 2D within 30 s of each other at baseline and at peak DSE. RESULTS: Real-time three-dimensional echocardiography and 2D showed good concordance in detection of abnormal LV wall motion at baseline (84%: Kappa = 0.59) and at peak DSE (88.9%: Kappa = 0.72). Left ventricular wall motion scores were similar at baseline and peak DSE using both techniques. Interobserver agreements for detection of ischemia at peak DSE were superior for RT-3D, 92.7% compared with 84.6% for 2D (p < 0.05). Mean scanning time at peak stress by RT-3D in 50 randomly selected patients was shorter, 27.4 +/- 10.7 s compared with 62.4 +/- 20.1 s by 2D (p < 0.0001). In 90 patients with coronary angiograms, RT-3D had a sensitivity of 87.9% in the detection of coronary artery disease (CAD) compared with 79.3% by 2D. CONCLUSIONS: Real-time three-dimensional dobutamine stress echocardiography is feasible and sensitive in the detection of CAD. The procedure offers shorter scanning time, superior interobserver agreements and unique new views of the LV.
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The results of a survey of 363 physicians performing echocardiography were evaluated to assess the relative safety of contrast echocardiography. Fifteen physicians reported a variety of transient side effects, including neurologic and respiratory symptoms. Although contrast echocardiography appeared to carry some risk for side effects, that risk was low (0.062%) and no residual side effects or complications were observed. In view of the significant benefits reported for contrast echocardiography, it appears to remain a valuable technique that is safer than currently available alternative diagnostic modalities. However, during contrast echocardiography, precautions should be taken to prevent the injection of visible amounts of air, especially in patients with a right to left shunt or arterial catheters.
Multiplane transesophageal echocardiography is a new development in transducer technology, which allows by rotation of the transducer to obtain not only transverse and longitudinal planes but also all intermediate planes. Exterior control allows continuous rotation of the scanning plane from the conventional transverse plane, corresponding to 0 degree, to the longitudinal plane, corresponding to 90 degrees and further to a left-right inverted transverse plane, corresponding to 180 degrees. Although the echoscope tip, which houses the rotatable transducer, is slightly larger than conventional probes, in our clinical experience of well over 400 cases, intubation of the esophagus is not more difficult than with the mono- or biplane probe. In comparison with the biplane technique the adjustment of intermediate planes is easier and less unpleasant for the patient, since mechanical irritation due to sideward flexion of the probe is less often necessary. Plane rotation, effected by control buttons in the echoscope handle, takes eight seconds from 0 degree to 180 degrees. The probe incorporates a 5 MHz phased array transducer, which alternatively works at 3.7 MHz. Pulsed, continuous and color Doppler are also integrated. Multiplane transesophageal echocardiography was used to investigate several clinical questions. In 41 patients with aortic valve stenosis the valve area was determined by planimetry. The valve area was measured in an individually aligned short axis view (between 50 degrees and 70 degrees). A high correlation (r = 0.95; Y = 0.9 X + 0.1; p < 0.01) with invasively determined valve areas by the Gorlin formula was found.(ABSTRACT TRUNCATED AT 250 WORDS)
UNLABELLED: The purpose of this study was to assess the role of transesophageal echocardiography in predicting the immediate and long-term outcome of balloon mitral valvuloplasty, and compare the results to transthoracic echocardiography. BACKGROUND: Transesophageal echocardiography accurately detects left atrial thrombi and allows better visualization of mitral valve morphology; however, its value in predicting the immediate and long-term outcome of balloon mitral valvuloplasty had not been assessed as adequately as for transthoracic echocardiography. METHODS: In 56 patients referred for balloon mitral valvuloplasty, both transesophageal and transthoracic echocardiography were performed (Group A). An echo score for both techniques was used to reflect mitral valve morphology, and its predictive value for immediate and long-term outcome of the valvuloplasty was assessed. The impact of transesophageal echocardiography in preventing procedural embolic events in those 56 patients was assessed by comparison to another group of 41 patients, who were examined only by transthoracic echocardiography prior to balloon mitral valvuloplasty (Group B). RESULTS: In Group A, transesophageal echocardiography detected left atrial thrombus in seven, while transthoracic echocardiography detected left atrial thrombus in two patients. After 2 months of warfarin therapy, a repeat transesophageal echo examination in four patients showed resolution of thrombus in three who went on to have balloon mitral valvuloplasty. Among the 52 patients who eventually had the procedure after thrombus was excluded by transesophageal echocardiography, there were no embolic events, compared to three embolic events among the 41 patients in Group B (P = 0.08). The transthoracic echocardiography scores, while slightly higher, correlated well with transesophageal echocardiography scores (r = 0.51, P < 0.001). The increase in mitral valve area did not correlate well to total transthoracic or transesophageal echocardiography scores, while it correlated negatively to valve calcification by transthoracic (r = -0.29, P < 0.05) and mobility by transesophageal echocardiography (r = -0.59, P < 0.02). At follow-up (7 +/- 4 months) nonsurvivors (7/56) had higher total scores by either transthoracic (P < 0.01) or transesophageal echocardiography (P < 0.05) compared to survivors. The percent reduction in mitral valve area was greater with age (r = 0.5, P < 0.02), time to follow-up (r = 0.67, P < 0.002), valve mobility by transthoracic echocardiography (r = 0.59, P < 0.01), and valve calcification by transthoracic echocardiography (r = 0.37, P = 0.09) and transesophageal echocardiography (r = 0.4, P = 0.07). CONCLUSIONS: Transesophageal echocardiography is superior to transthoracic echocardiography in detecting left atrial thrombi, and it may reduce the risk of embolic events following balloon mitral valvuloplasty. Assessment of mitral valve morphology by transesophageal echocardiography is complementary and not superior to assessment by transthoracic echocardiography. Mitral valve calcification and mobility appear to be the best morphological predictors of immediate and long-term outcome following balloon mitral valvuloplasty.
Although the yield of potential cardiac sources of embolism by echocardiography in patients with stroke and arterial embolism has been low, with the advent of transesophageal echocardiography, a renewed enthusiasm for echocardiography in these patients has developed. This article reviews the six major studies comparing transthoracic to transesophageal echocardiography in the search for potential cardiac sources of embolism. The overall yield of transesophageal echocardiography in these studies for potential cardiac sources of embolism is 43% compared to 14% by transthoracic echocardiography in a total of 367 patients. In patients without clinical cardiac disease, the yield is lower but still substantially higher by transesophageal echocardiography (24% compared to 7% by transthoracic echocardiography). For left atrial thrombus, left atrial spontaneous contrast, patent foreman ovale, and atrial septal aneurysm (ASA), transesophageal echocardiography is clearly superior than transthoracic echocardiography. Data on the detection of mitral valve prolapse and left ventricular thrombus are conflicting and neither method is clearly superior. In addition, transesophageal echocardiography identifies certain abnormalities including debris in the aorta and prosthetic strands that transthoracic echocardiography is incapable of identifying. Although transthoracic echocardiography should continue to be the initial screening modality for stroke patients, transesophageal echocardiography should be performed when surface findings are negative or equivocal in patients with likely cardioembolic stroke.
BACKGROUND: Echocardiography based myocardial perfusion imaging and regional wall motion analysis are used for evaluation of coronary artery disease and regional myocardial abnormalities. AIM: This study sought to compare myocardial contrast echocardiography (MCE) and 2D echocardiography with regard to interobserver variability and detection of regional myocardial abnormalities. METHODS: In 70 patients evenly distributed between three ejection fraction groups based on biplane cineventriculography ( > 55%, 35-55%, < 35%), unenhanced and contrast enhanced 2D echocardiography and myocardial contrast echocardiography (MCE; SonoVue; Bracco) were performed. Regional wall motion and myocardial perfusion were assessed referring to a 16 segment model. Interobserver agreement (IOA) among 2 readers was determined within each imaging modality. To define a standard of truth for the presence of segmental myocardial disease an independent expert-panel decision was obtained based on clinical data, ECG, coronary angiography and blinded information from the imaging modalities. RESULTS: Regional wall motion assessment was possible in 98.1% of segments using contrast enhanced 2D echocardiography and in 87.2% using unenhanced 2D echocardiography (p < 0.001), while perfusion assessment was possible in 90.1% of segments (p < 0.001). IOA on presence of any regional wall motion abnormality expressed as Kappa coefficient was 0.71 (95% CI 0.53-0.89) for contrast enhanced echocardiography and 0.37 (95% CI 0.14-0.59) for unenhanced echocardiography. IOA on presence of any perfusion abnormality was 0.53 (95% CI 0.34-0.73). For MCE there was high IOA for the apical segments (kappa = 0.57) and lower IOA for the basal segments (kappa=0.14), while no such gradient was found for the IOA on wall motion abnormalities. Mean accuracy to detect expert-panel defined myocardial abnormalities was 80.6% for unenhanced echocardiography, 85.0% for contrast enhanced 2D echocardiography and 80.6% for MCE. CONCLUSIONS: MCE is inferior to contrast enhanced 2D echocardiography with regard to visibility of all LV segments and appears slightly inferior with regards to IOA, while both are superior to unenhanced 2D echocardiography. The methods demonstrated high accuracy in detection of panel defined regional myocardial abnormalities.
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The diagnostic value of dobutamine stress echocardiography, myocardial contrast echocardiography and dipyridamole stress thallium-201 single photon emission computed tomography (SPECT) for predicting recovery of wall motion abnormality after revascularization was evaluated in 13 patients with postmyocardial infarction. Seventeen segments showed severe wall motion abnormalities before revascularization. Nine segments which had relatively good Tl uptake on delayed SPECT images despite severely abnormal wall motion were opacified during myocardial contrast echocardiography, and showed improved wall motion after revascularization. In contrast, three segments which had poor Tl uptake and severely abnormal wall motion were not opacified during myocardial contrast echocardiography, and showed no improvement in wall motion during dobutamine stress echocardiography and after revascularization. The following three findings were assumed to be signs of myocardial viability: 1) good Tl uptake on delayed SPECT images; 2) improved wall motion by dobutamine stress echocardiography; and 3) positive opacification of the myocardium by myocardial contrast echocardiography. Myocardial contrast echocardiography had the highest sensitivity (100%) and negative predictive value (100%). Delayed SPECT images had the highest specificity (100%) and positive predictive value (100%). Dobutamine stress echocardiography had a sensitivity of 83.0%, specificity of 80.0%, positive predictive value of 90.9%, and negative predictive value of 66.7%, respectively. Myocardial contrast echocardiography showed the lowest specificity (60.0%). The techniques of dobutamine stress echocardiography and SPECT, though noninvasive, may underestimate wall motion improvement after revascularization. Further examination by myocardial contrast echocardiography is recommended to assess myocardial viability for determining the indications for coronary revascularization in spite of its invasiveness.
BACKGROUND: The purpose of this study was to investigate the discrepancy between intraoperative transesophageal and postoperative transthoracic echocardiography in assessing residual regurgitation in children undergoing valve repair. METHODS: Forty-two consecutive children (median age, 5.1 years) who underwent valve repair for valvar regurgitation from 2001 to 2004 were retrospectively analyzed. The patients were divided into two groups: atrioventricular valve group (n = 33) and aortic valve group (n = 9). Regurgitation grade, fractional shortening, and atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography were compared with those obtained by transthoracic echocardiography at discharge (median, 11 days) and at follow-up (median, 8 months). RESULTS: Intraoperative transesophageal echocardiography revealed specific residual lesions in 4 patients, leading to successful re-repair. Fractional shortening obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the atrioventricular valve group, the regurgitation grade obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (0.7 +/- 0.8 versus 1.4 +/- 0.9; p < 0.01), and agreement between the two examinations was found in 12 patients (38%). Peak atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the aortic valve group, there was no significant difference between the regurgitation grades in the two examinations (0.8 +/- 0.8 versus 1.1 +/- 0.9), and complete agreement in regurgitation grade was found in 5 (56%) of 9 patients. CONCLUSIONS: There were considerable discrepancies between the examinations in evaluation of residual atrioventricular valve regurgitation and potential atrioventricular valve stenosis: most of the residual regurgitations were underestimated by intraoperative transesophageal echocardiography. In contrast, reasonable agreement was found between the two examinations in evaluation of aortic valve regurgitation.
The purpose of this study was to compare transthoracic and transesophageal echocardiography in the diagnosis of various types of atrial septal defects. Forty-one adult patients with the clinical diagnosis of atrial septal defect were studied by transthoracic and transesophageal echocardiography (30 women, 11 men; 18 to 81 years of age). Transthoracic echocardiography demonstrated the atrial septal defect in 33 patients (secundum type in 28, primum type in 3 and sinus venosus type in 2). Transesophageal echocardiography demonstrated the defect in all 41 patients. Thus, in 8 (20%) of 41 patients the atrial septal defect was demonstrated by transesophageal and not by transthoracic echocardiography. Six of the eight had a sinus venosus type atrial septal defect; the other two patients had a secundum atrial septal defect (one of these two had a technically poor transthoracic echocardiogram and the other had a small atrial septal defect). Transthoracic echocardiography, therefore, failed to demonstrate the sinus venosus defect in six (75%) of eight patients. An anomalous venous connection associated with the sinus venosus defect was visualized by transesophageal echocardiography in seven of the eight patients but was not seen on transthoracic echocardiography in any patient. Sinus venosus type atrial septal defects are frequently not visualized in adults by conventional transthoracic echocardiography. Transesophageal echocardiography is recommended when an atrial septal defect is clinically suspected but cannot be visualized by transthoracic echocardiography.