Transcript

Hi, I am Dr. Jason Cox,

and I'd like to welcome you to Best Practices

to Avoid Common Errors in Cardiac Sonography Measurements

for 2024.

This webinar is brought to you by the Institute

for Advanced Medical Education.

So again, uh, for everybody here, I'm Dr. Jason Cox.

I'll be, uh, moderating this talk, um, with Dr.

Friedman, uh, the cardiologist expert in echocardiography,

uh, Jess Huey and Brittany James, who are, um, experts in,

uh, cardiac sonography

and, uh, performing the echoes, um, the housekeeping things

that, um, some people I see are asking about

or about the CME.

Um, we'll, we'll, um, get to that here in a second.

And, um, you know, I, I do wanna say

that this is A-C-C-M-E accredited

and none of the people

that have participated in this have any, uh,

financial disclosures.

So, um, the webinar's divided into two parts.

Again, uh, the first part, um, we'll go through

and then we will take a, a brief, uh, pause

to just go over some questions from the audience.

Um, then we'll go into the second part

and then, um, we will then have the ability to,

uh, have a complete q and a at the end of that.

Um, if to claim the credit, um,

you've gotta stay till the end of the presentation.

We'll show a QR code,

and then we'll also, um, we'll also show, um,

you know, the link to the website, everybody

that's here and then registered.

We'll also get an email to, uh, with instructions on how

to get the, um, the CME.

So without further ado, um, I'd like to introduce, uh,

Jess Hu and uh, uh, Brittany James,

who are gonna take it from here to talk about the first, uh,

part and the first sort four uh, sections of the talk.

The first topic we're going to review is patient history

and indication for an echocardiogram.

I, Before we get into

the actual measurements, it's important to point out

that in addition to images

and measurements, the indication for the order along

with the patient history should always be the first thing

assessed before beginning the exam, so you have an idea of

what extra measurements or views might be needed.

Let's review a few examples of why it is helpful

to look at the patient's chart

for our first clinical scenario.

A patient has a prior history of systemic lupus

and is scheduled for an echocardiogram.

The indication for the exam,

however, was atypical chest pain.

Why would it be important to know about the lupus?

The answer is in the case of a patient with a history

of systemic lupus, an echocardiogram is

crucial for several reasons.

Lupus is known to possibly affect multiple organs,

including the heart.

An echocardiogram helps assess

for potential cardiac complications such as pericarditis,

myocarditis, or valvular abnormalities

that can arise from autoimmune activity.

Monitoring cardiac function through an echo is essential

for early detection of any lupus related cardiovascular

involvement, enabling timely intervention

and appropriate management to prevent further damage

and optimize a patient's overall health.

Let's take a look at another clinical scenario.

A patient with a history of rheumatic fever is referred

for an echocardiogram.

However, the indication on the order is dyspnea.

Why is the history important for this echo?

For a patient with a history of rheumatic fever,

an echocardiogram is essential for detecting

and monitoring rheumatic heart disease.

It allows for the assessment of valvular involvement,

the presence of valvular stenosis or regurgitation,

and overall cardiac function.

This information is critical

for guiding long-term management

and preventing further complications.

For our third clinical scenario, a patient

with an indication of unexplained fatigue

and weakness was sent to have an echo reading

through the patient's chart.

They have a history of chemotherapy for cancer treatment.

Why is this important? Given the history of chemotherapy?

An echocardiogram is important to assess cardiac function.

Certain chemotherapeutic agents may have cardiotoxic

effects, and an echo can detect early signs

of cardiomyopathy

or other cardiac abnormalities with strain analysis.

This information is vital for timely intervention

and adjustment of cancer treatment

to minimize potential cardiac complications.

For our last clinical scenario, a pregnant woman is sent

to the lab for an echo with an indication of chest pain.

After reading through the patient's chart, it is also noted

that they have a history of congenital heart disease

with prior cardiac surgery.

As a child, why is this important to know?

The answer is in the context of a pregnant woman

with a history of congenital heart disease.

An echocardiogram is essential for assessing the structural

and functional status of the heart.

It helps evaluate the impact

of the preexisting condition on maternal

and fetal wellbeing, allowing for informed decisions

regarding pregnancy management and delivery planning.

The second topic we'll review is left ventricular

ejection fraction measurements.

Calculating an ejection fraction is such an important

measurement to get accurate.

As many patients, especially those with heart conditions,

can have the EF calculation help determine the

correct treatment plan.

There are several methods that can be used

to calculate the ef, but let's start with biplane.

Simpson. Biplane calculation involves tracing the LV

blood tissue interface or endocardium in the four

and two chamber view in both diastole and systole.

Some labs do not require biplane measurements on all

patients, but biplane EF is especially important when there

are regional wall motion abnormalities present

as it takes into calculation more walls in the lv.

Before measuring biplane measurements though,

make sure you are optimizing the image

so you can see all walls, as well

as making sure the LV apex is not for shortened.

Looking at this first video,

do you notice anything wrong with the lv?

So it looks like a pretty decent four chamber view

with good LV function.

However, if you notice that LV apex is being foreshortened,

meaning the apex is coming down into the LV towards the

base,

So how do we fix this?

To fix an apical for shortened view slide, the probe lateral

and possibly even down a rib space in order

to bring the true LV apex in.

As you can see on this clip,

which is from the same patient from the previous slide,

many times having the patient take a breath in

or out, even on the for shortened view,

can help bring the image in more clearly.

This patient required a deep breath in as well

as a more lateral position to get this view,

but it is now very clear where the LV apex is

and we know the biplane measurement will be accurate.

While this might not seem like a big deal,

you can actually overestimate the EF

and even miss regional wall motion abnormalities in the apex

by not truly seeing the LV open completely,

especially if the para sternal view did not show the apex

well from short axis.

So after you know you have an optimized image,

let's look at the actual measurements.

After viewing this clip, ask yourself

what you think the visual estimated ejection fraction is.

So these are the measurements

that were taken on this patient.

You can see that the EF was calculated at 28%.

Is this what you thought from the video

in the previous slide?

Hopefully not. Obviously,

the ejection fraction was not visually less than 30%,

so we have to take a closer look

and see why the measurements are not matching our

visual estimation.

Could it be that there isn't the correct timing

of the cardiac cycle?

Is it the image quality?

So the timing and image quality were good as well

as the diastolic tracing,

but let's take a look at the systolic trace closer.

When you look closer at the systolic image,

you see two things wrong.

First, the view is rotated slightly from a

true four chamber.

So during systole,

you start seeing the aortic valve come into view at the base

of the left ventricle due to the twisty motion of the heart

as seen in the first image with the blue circle.

The second issue, which is the biggest issue,

is if you take a closer look at the apex

and turn the gains up a little, you can see

that the wall is actually further into the left ventricle

cavity where the blue line is versus

where the trace was originally done.

Correcting these two things would have increased the EF

calculation to the normal range.

So to review what we just saw first

before you measure, always make sure to optimize your image

by making sure the true apex is being seen versus a four

shortened view in both the four chamber and two chamber.

Second, do not trace around the papillary muscle

or trabeculation, include them within the trace.

This is especially important during

systolic trace at the apex where it's harder to define

where the blood tissue interface is versus trabeculation.

Third, you do want to trace

around an increased basal septal thickening.

Fourth, the gains should be adjusted slightly higher

to see the endocardium.

Lastly, if you have access to contrast, it can be helpful,

especially on those technically difficult studies,

and you can still do biplane measurements.

The most common measurement

for EF is from the peral long axis view,

which if you are in an IAC accredited lab,

this is a required measurement.

Looking at this video,

which you can see is a low peral long axis view

because it was very technically difficult.

What do you think the EF is? Is it normal? Is it abnormal?

So the EF calculated 90%, is that

what you were thinking from the clip?

Again, hopefully not as, this would not be accurate.

So let's review the measurements to see

where the air was made.

Looking at the first image,

the diastolic measurements look pretty good.

No major issues there. Now let's look at the systolic.

Looking closer at the systolic measurement,

you can see the anterior measurement placement looks good,

but when you look closer at

where the posterior measurement was placed,

it was actually on the papillary muscle instead

of the LV wall, which is demonstrated by the arrow.

So as you can see in this example,

one mistake can overestimate the LV EF.

So make sure to look at the calculation

before you acquire an image.

Another thing to point out

that can be an issue is being mindful

of the direction of the measurement.

In these images, the measurements were not perpendicular

to the angle of the lv, which is demonstrated

by the blue line.

You should also measure towards the base of the LV instead

of the mid that was done here.

While this won't have quite the impact on EF calculation

errors, it is important

to ensure accuracy in every measurement we do.

So after looking at some incorrect measurements,

here is a case of correct measurements.

This patient has dilated cardiomyopathy

and is post mitral valve replacement.

The EF calculated 18%,

but it's important to note

that the biplane measurement would be preferred in cases

like these, which were not performed.

One last example for EF measurements.

This image shows that the EF calculated negative 1%,

and the scary thing is that this

actually went into the patient's chart

in the measurement section.

So if you see that the EF is negative 1%,

you should never acquire the image,

but instead readjust the view

and try to measure, again, if this was a true negative 1%,

you should be calling a code.

So as we saw, it's easy to make mistakes on measurements.

If you don't pay attention, we can stress enough.

The importance of looking at the numbers

and calculations you get

before storing the image, which makes it a permanent part

of the patient's medical history.

This is one of the reasons that things get called incorrect.

The third topic is aortic stenosis,

as is another pathology that is often underestimated due

to incorrect measurements.

We could actually talk the rest

of the presentation on this topic

as it is pretty common pathology,

but we'll give you a brief glimpse into some

of the most common errors we've seen

When measuring the severity of

as if the values are falling into a different severity grade

of stenosis, which is demonstrated by this chart.

You should go back, check for errors

and look for other reasons.

The numbers don't all fall into the same category range.

A few tips on what we typically see as the culprit are.

One is the LVOT diameter measured correctly.

If it's measured too small,

the aortic valve area will be smaller than it actually is,

and therefore overestimating the severity.

On the other hand, if it's measured too large,

the aortic valve area will be larger than it actually is,

and therefore underestimating the severity.

The other main issue seen is CW signal

not being accurate.

Since the CW signal gives us both peak velocity

and mean gradient, which are two of the measurements used

to grade the severity as seen in the chart, getting parallel

to flow is a must.

In order to be accurate, always try doing a visual estimate

of the severity from your peroneal short axis view

of the aortic valve,

and if it is not matching what you get with cw,

it's probably not parallel to flow.

PDOF probe is the best way to get parallel to flow

as it allows attempting continuous wave from

multiple different angles.

So first thing, make sure the LVOT diameter is correct

as it's such an important measurement since in the equation

used to calculate the aortic valve area,

that number is squared,

which means any mistake is also then squared

to ensure optimal LVOT diameter.

Similar to getting an accurate ef,

you should always optimize the image before measuring.

Do this by zooming on the aortic valve from the peral long

axis view, which can help eliminate measurement air

as you'll be able to see the valve clearer.

Next, turn down the gains

as it'll give you the image a more precise picture of

what needs to be measured and gives you more confidence

and measurement accuracy.

This can be especially helpful in cases

where the aortic valve is heavily cal calcified

measurement is done during mid systole

and is inner to inner edge near the aortic annulus at the

base of the leaflets.

This is an example of A-L-V-O-T diameter measurement

that was not optimized at all.

It was measured at 3.4 centimeters,

but they did not zoom in on the A v.

The gains were turned up too high,

and the EKG signal makes it hard to see where to measure.

Let's face it, most people dread using the PDO probe,

but it should always be used on patients

with aortic stenosis.

This is also an IAC requirement.

Some of the most common views

to try using the PDO probe are from the apical,

which is done with the patient on their left side

super sternal notch

and right supraclavicular are done

with the patient on their back right para sternal border,

which is done with the patient on their right side.

Just remember, the more you use the PDOF probe,

the easier it gets to get a good signal.

So don't give up.

Here's a great example of why we use the P ddo probe.

The patient had good images in this example,

and from parasternal short access of the aortic valve,

you can see there significant stenosis with that in mind.

When the CW Doppler signal was obtained,

the best signal they could get was not matching

what they thought the severity was from the short axis view.

Using the PDO probe, they were able

to get a much more accurate signal than the apical view,

and now all the parameters match the severe category.

Why was the apical CW signal so far off on this patient?

You always hear you need to be parallel to flow,

but this is not necessarily going to be parallel

to the aortic valve itself.

If you look at the image shown here, you can see that

because of the calcification on the valve,

it changed the flow path through the valve.

In this instance, by seeing how off axis the apical view is

to being aligned, you can tell

that the PDO F right para sternal view is going

to be more accurate.

The best tip is to use PDO probe on every AS exam

because the more you use it, the better you'll get

and remember, it's required by accreditation.

Lastly, remember that you do not have

to have great images in order to get good doppler.

Our fourth topic is mitral inflow.

Using pulse wave at the mitral valve leaflet tips is used

to help determine if there is diastolic dysfunction

and if there is what grade of dysfunction there is.

Looking at these examples, are they accurate measurements

of mitral e and a waves?

Before placing your measurement,

always look at the ECG signal to confirm

that you're measuring during diastole.

In these two examples, an a wave measurement was done,

but looking closer to the ECG, it is actually occurring

during Sicily, therefore it should have not been measured.

Also, make sure your ECG signal is easy to see the QRS,

so you can differentiate Sicily

and diastole before measuring.

This is another case of an incorrect measurement where

because of a higher heart rate 93, the mitral e

and a waves were fused.

So in this case, there should not have been a measurement

of either the E or a wave.

When the signal is fused due to increased heart rate,

you cannot grade the diastolic function

and it would be considered indeterminate.

Let's take a look at this image.

Should this have been measured? The answer is no.

In this example, the patient had severe aortic

regurgitation, making the mitral inflow difficult to see.

Even though you can see the ewa, it is not certain

that the EWA is where this was measured.

All right, um, Brittany

and, uh, Jess have just gone through some, uh,

significant material here.

Um, let's go ahead

and take some comments, uh, from the audience

and discuss those here.

Um, let's see.

So, um,

we had some a question about, um, how off

or how much time are, are techs completing scans?

Um, Jess?

Yeah, so typically what we're seeing is that, um,

techs aren't really given a lot

of time in some labs just due to the volume

that they wanna see,

but, um, technically we're supposed

to allow 45 minutes for a full exam.

Mm-hmm. I'm sure Dr.

Friedman would be able to kind of speak

to that a little bit more.

Dr. Friedman, you're, um, you're,

you're muted there, thank you.

45 minutes, which includes in addition to the scanning,

the, the, the prepping positioning, um,

starting in the computer,

entering the patient demographic information.

So, um, I don't know anyone in the real world

who has the full 45 minutes

and all that has to be taken into account, um, which is why,

you know, you really brought up some excellent key pieces

of information, know why the study's being done.

Let's say for example, the, the diagnosis is murmur,

and you see a patient who's about an 85-year-old female.

What would be the most common murmur in

the 85-year-old female?

Not, not like an a, uh, pulmonary stenosis,

probably aortic stenosis.

Then one step further, you go and you, you go

and you start the echo and you see the aortic valve is

severely calcified with restricted motion,

so you know they have aortic stenosis.

Then let's go all the way to the end,

then make sure the measurements are right.

Don't, don't accept a measurement.

Then when everything is lining up that we know that the,

the di di diagnosis is going to be severe aortic stenosis,

and then because of A-L-V-O-T error

or one of the other errors that you mentioned,

continuous wave being off

or not doing the p doff, then, then we come out

with a valve area of 2.9.

When visually it's probably, you know,

less than one centimeter.

Uh, if, if, if things just don't add up, stop and,

and fix it, because this is the one chance we have

to get the patient their diagnosis.

Um, and, and usually it's, it's, mm-hmm. It's right there.

Same thing with the ef.

Don't, don't click save with the minus 1%

and go on to the next patient.

I mean, I, I see this, I see the 97%. I see it every day.

I wanna bang my head against the wall.

Um, we, we all have, once you've done a hundred echoes,

you can do a visual EF with a para sternal, you know, um,

that being said, MM mode from the para sternal is not the EF

that can be really adopted either.

Uh, you know, and documented.

We, we need to get multiple views

and, uh, know why, know why the echo's being done.

If you see the pathology,

make sure the measurements match the pathology stop,

make sure it's done right.

Um, and let's be honest, if, if,

if the whole echo pointed towards the aortic stenosis,

do we need to do 10 measurements of the pulmonary valve?

You know, you can save time in other ways.

Um, you know, we, we, we, we, we want to put the, the time

where the, where the biggest bang for the buck is there,

and, and when it stares us right in the

face, let's not mess it up.

Great point. Um,

we had a couple other comments about, um, let's see,

IAC protocols,

and then how often do you see, um, biplane

actually being, uh, measured?

Um, I had an accredited IKO lab,

and they, they require submissions of, of sample echoes,

and they will not renew your accreditation

unless you meet their criteria.

Mm-hmm. So in that environment,

everything was done according to their protocols, um,

by plane imaging.

Um, and, uh, what you mentioned

before, uh, there, there was no, there was no way not

to do it right In, in mobile settings,

portable settings are, are, are, you know, I I would say if,

if you're going just to do a quick,

I need the EF on this patient,

and that's all I need, I need

to know if they have a pericardial effusion.

I say, well, there's a role for the limited echo as well,

and, and you document that this is limited echo

for ef limited echo for pericardial effusion.

Mm-hmm. Then, then, then an echo

that doesn't meet the full criteria.

Maybe it's a follow-up echo to document resolution

of pericardial effusion in those, in those cases,

we wouldn't expect the protocol to be fully,

um, you know, expressed.

But I, I imagine anybody doing echo

in a hospital environment, I would assume 99%

of the hospitals are accredited.

And again, all, all the, um, all the work is saved

and all the work can be essentially subpoenaed

by the accreditation bureau who wants to review

and make sure that it's being done correctly.

They're very nasty. If you don't do it right, they will,

they will fail you and yank your accreditation.

Um, you gotta, you gotta do it right.

Yeah. Well, those are some great questions

and, uh, comments from the, from the, um, participants.

Um, we'll go ahead and move on to, uh, part two.

Um, I, I'm not sure who's gonna start that off, Jess

or, or, or Brittany.

So we'll go ahead and, uh, we'll jump right in.

Our fifth topic to discuss is right heart.

There are many different aspects of the right heart

that we can assess with echo.

Unfortunately, many labs do not require much measuring

of the right heart other than trying

for tricuspid regurgitation,

but we want to show

that even tricuspid regurgitation measurements need

to be optimized as you can gain

so much valuable information.

So, like we mentioned, when you look at most lab protocols,

measurements of the right heart are often not required.

Because of this, there's often not much effort put into

focusing on the right side to properly assess.

Getting a RV focus view is helpful,

not just when the RV is enlarge,

but for TR alignment as well.

A SC recommends a three point measurement of the RV

where measurements are taken at the base mid

and apex to annulus length.

In this image, the RV measurement could have been better.

So here's some tips to help ensure accuracy.

One, make sure the ECG tracing is optimized

so you know you are measuring at in diastole.

Two, make sure to measure all the way into the apex.

And three, measure the RV base, not the CUSA valve.

Annulus.

TAPI stands for tricuspid annular plane systolic excursion

and is measured using M mode from the apical four chamber

view view.

This is a distance measurement of how much the lateral

RV wall moves from in diastole to peak systole.

The main issue seen

with this measurement is measuring without a clear line

and having to then guess where to place measurement points

to help better visualize on technically difficult studies.

You can try adding tissue doppler

to the M mode as seen here.

You can see how it makes the wall more defined.

Some tips to help measure are

try zooming on the lateral annulus

to help define the movement of the wall.

Turn the gains down so you can see at least one clear line

move to a para apical view, which you can get

by moving the probe slightly medial towards the sternum so

that you have a better angle on the wall,

and also sometimes a clear image as a note.

This is also a good place to try TR as well.

TAP C helps assess the RV systolic function,

and since you are measuring to the millimeter,

make sure you can see it clear enough.

If your sample placement is too far into the wall,

you can get too many lines

and might not be able to clearly tell which one to measure.

S prime is pulse wave tissue.

Doppler of the lateral tricuspid annulus

measured in systole, similar

to tap CRVS Prime is another way

to evaluate the RV systolic function.

Measure in the same plane that you measure TAP C

to optimize, turn the gains down.

So you could see the true systolic peak

measuring T should be attempted on every exam

and in multiple views.

A couple of common mistakes that can happen

with obtaining this measurement are, number one,

not being parallel to flow.

This is why it's so important to try

for TR in multiple views,

so you know you're getting the highest signal.

And number two, measuring artifact.

Here's an example of measuring artifact.

This image shows an example of an overestimated TRV max,

which will also overestimate the RVSP.

If you look closer at the image on the right,

the measurement should have been

where the line is drawn across the rounding of the signal.

The signal could have been optimized

by simply decreasing the doppler scale, which was set

to six, allowing a clear image of where to measure.

So going back to why we need

to attempt TR from multiple views.

Here's an example of that.

This was a technically difficult study,

which you can see from the video

and even from an RV focus for chamber view.

The TR was not well seen with color or with cw.

The tech tried to optimize further

by sliding the probe slightly medial

and up towards the para sternal view,

which is sometimes called the para apical view,

which is basically adjusting from a four chamber view

by sliding the probe up a rib space

and medial with a, a slight tilt down.

Even though there isn't much of a difference in the 2D

and color clip, you can definitely see the difference it

made in the CW signal.

You can now confidently measure the TR velocity.

Let's look at one more example of adjusting the view

to optimize the TR in this study.

The initial signal actually looks pretty good,

but by moving to a slightly more medial view,

you can now see the RV clear

and the TR peak velocity went from 2.8 to 3.2.

This is a good example of

how just small adjustments can make big differences in

the data that we get.

Here is a couple other examples of issues we've seen

with the first image.

The gains are turned down too much,

making it a guessing game of where the peak tr velocity is.

This should have been optimized

before attempting to measure in the second image.

The scale is set too high at six

when the tier velocity was less than three.

By making the scale that high, the chances

of being inaccurate are much higher

To review.

Try using unconventional views like the para apical view we

mentioned, or even trying from subcostal.

Take measurements during inspiration

or when the signal is the highest velocity

as TR is typically most pronounced.

During this phase, you can try

to elevate the patient's legs,

which will boost the venous return

and accentuate the TR signal.

Agitated saline or contrast can enhance the TR doppler

signal, which is especially helpful on technically

difficult exams.

However, over measuring is more common, so you will need

to optimize by turning the gains down

as shown in this example.

One consideration

to keep in mind is when there is not tricuspid valve leaflet

coaptation creating severe tr,

the peak velocity will be underestimated due

to the rapid pressure equalization

between the RA and the rv.

In this setting, RVSP will not be a true

representation of the pressure.

Our next topic is on the left atrium.

The left atrial volume index is a more accurate measurement

of the left atrium as it accounts

for variations in body size, indexing it

to the body surface area resulting in the left

atrial volume index.

What can go wrong with the left atrium trace?

Well, looking at this example, you could see from the video

that this patient has a mitral valve replacement.

This creates artifact

and shadowing in the left atrium, making it hard to see

The trace that was done,

missed a large portion of the left atrium.

So in these instances, a trace should not have been done

as it will be inaccurate.

Here's an example of an accurate trace,

but it's also important to pay attention

where the length measurement is placed.

The machine will automatically place the length for you,

but you can move this

before storing the image

as the machine is not always accurate,

especially on traces like this one

that had an atrial septal aneurysm.

Some common mistakes to watch out for are

not tracing the left atrium at in systole

where it's the largest and not starting the trace from the

mitral valve annulus level in both apical four

and two chamber views.

Four, shortening the left atrium.

Remember the heart is a 3D structure

and we are seeing a 2D slice, so make sure to scan

through the left atrium to open it up completely.

Make sure to also not measure into the pulmonary veins.

Our next topic is on LV hypertrophy and obstruction.

Holcomb, which stands

for hypertrophic obstructive cardiomyopathy, can be tricky

to assess, especially when the obstruction is occurring in

the LVOT LV outflow.

Track obstruction can occur when the LV outflow track is

narrowed from the basal septum hypertrophy,

Which can also be referred to as sigmoid septum,

causing an increased gradient.

This video shows an example

of severe basal septal hypertrophy,

and by looking at the mitral valve, Sam, along

with the septum, you can assume there will probably be at

least some level of obstruction

in this video.

If you see this much aliasing color as demonstrated here,

you should make sure to assess for any obstruction

To review.

Echo. Assessment of hoku involves using pulse wave Doppler

to confirm the location as

hypertrophic cardiomyopathy can occur in multiple places,

not just the LVOT.

After confirming the location, you'll obtain a CW Doppler

through the area of obstruction at rest,

and with Valsalva,

the signal will be a late systolic peeking jet

as seen in this image.

Remember, you do not have to trace the signal.

It is measured by placing a caliper at the peak

of the signal, giving you a peak gradient and velocity.

A peak gradient should be at least 30 millimeters

of mercury at rest to diagnose

as obstructive hypertrophic cardiomyopathy.

Our final topic is PFO assessment.

Since one in four people have a patent form in oval

or PFO, it's important to evaluate the inter atrial septum

with color doppler on every patient.

The best window

for viewing the inter atrial septum is from subcostal

with the color scale turned down

as demonstrated in this video, which shows a large PFO.

Other views that can be used

to assess the atrial septum are from parasternal short

access, apical four chamber and subcostal short access view.

This example of a 26-year-old female who came in for an echo

with bubble study due to migraines.

You can see even from the peroneal short axis view color on

the inter atrial septum shows a possible shunt.

The subcostal window also confirms this.

The first video is of the bubble study with Fal Salva,

which you can clearly see multiple bubbles coming

across into the LALV.

This patient was sent

to have an amplatzer PFO occluded device placed,

which is demonstrated by the second video.

While this exam didn't have measuring issues, it's helpful

to see the whole process of why we need

to make sure every study is done thoroughly.

On the last example, the images are good quality

and it was clear that there was a shunt,

but now let's look at more of an everyday patient

that has suboptimal images.

During an echo,

you should always attempt color on the inter atrial septum

from the subcostal window

on this patient color on the septum from other views did not

show any indication of A PFO.

However, from subcostal with zooming

and turning the color scale down,

although small, you can now see flow across.

You can also try to confirm with doppler on the septum

as demonstrated here.

The best way to confirm an inter atrial shunt, though is

with an agitated saline or bubble study.

This example is of a patient

with an interatrial septal aneurysm,

and the bubble study demonstrates a shot

Performing a bubble study requires injection at rest,

and then another injection with Valsalva.

Many times the Valsalva clip shows the image disappearing.

The correct way to do a Valsalva study is

to first set the machine to acquire eight to 10 beats.

Second, have the patient practice Val Salva

so that they, you know, if the image window is going

to disappear with the Val Salva maneuver.

Third, inject the agitated saline

and have the patient hold the Val Salva

until bubbles are seen entering into the right atrium.

And at that point, you can have the patient release.

It is on the release of the Val Salva

that you typically see bubbles crossing.

One tip for optimizing is

to have the patient stop breathing without taking a deep

breath in while they val salva.

That way the window will not move as much on the release.

Our final main takeaway points would be to, number one,

always verify your numbers

before storing an image to check for accuracy.

Second, don't be afraid to think outside the box

for image optimization and try new views, angles,

and adjustments of the probe

or even repositioning the patient.

You can also try experimenting with breath holds in

or out to get the best image

so your measurements will be accurate.

So in conclusion, we hope this has been helpful

and you are able to pick up a few tips that you'll be able

to use in your lab.

All right, thanks, uh, Jess and, uh, Brittany.

Um, we're gonna bring everybody out now

and we're gonna move on to our, uh, q and A session.

Um, it looks like we've got about nine minutes

left, um, to do this.

So, um, we've had several, uh, good comments

and questions coming from the audience.

Um, and, um, you know, let's,

we'll go ahead and, and start, we'll kind

of throw those up on the screen and then, you know,

if it's a question or a comment, we'll just have our, uh,

panel here, talk about it.

Okay. So somebody says

that they use a V one V two measurement in addition to, um,

avi a to determine the degree of aortic stenosis.

Um, do you guys find that to be contributory to your exam

or, or is that something that you typically do

There? There are other,

um, ways to get the degree of,

as there's classically the dimensionless index.

Um, this is often used

with prosthetic valve stenosis as well.

Um, you know, when we're looking at the clinical

and we're trying to see when the patient crosses over the

severe as boundary

and needs the, uh, valve replaced for severe stenosis,

really the guidelines are using the, the VM max

of 4.0 meters per second

and a mean gradient greater than 40.

And, um, you know, ideally those measurements track directly

to the guidelines, which then move the patient towards, uh,

and that's what the surgeons understand.

So that's the kind of language that mm-hmm.

We speak most of the time.

But, but you know, there are times

where imaging requires something else and the V one V two

or the dimensionless index, you know, less than 0.25

or one of these other measuring modalities, um,

could also be used as well.

Um, keep in mind too,

everything gets thrown off a little bit.

We didn't even talk about this,

but with combined valve disease where you have regurgitation

with stenosis, that's going to going

to affect your aortic valve area a little bit too.

So that's why, um, aortic valve area in

and of itself, less than 1.0 has not become the

standard of severe stenosis.

It really relies on the, the velocity maximum

and the, uh, mean gradient.

Okay, thanks a lot, Dr. Um, Freeman. Um, let's see.

Let's move on to our next, uh, comment.

And so, okay, let's see.

Have to be gradients won't mash

visual estimation.

I think what that's saying is, you know, you,

you see a severe as visually and your gradients,

although this is really why the poff probe was invented.

Oh, yeah. Okay. So you can kind

of get a different angle with a smaller probe head, uh,

pointed at that little tiny, um, hole that,

that the valve now has

and, uh, try to get the, the velocity more accurately.

Mm-hmm. Um, without it, it's, it's very hard to, uh, do

and keep in mind, um, if the, if the echo fails to,

to get a diagnosis, the next di the next step is

TEE, which is mm-hmm.

Which is terribly invasive.

It's a huge probe trying, you know, aortic stenosis,

the most common valve disease, you know,

that we see typically, um, mostly in the elderly

to take a frail elderly lady who might be a TAVR candidate

and, and subject them to a TEE, uh, it's, it's brutal.

It's brutal. Um, mm-hmm.

You know, one of the few times where

Tet Trumps TEE is things like aortic stenosis.

You do not need to get a te to go to go

to valve replacement if the, if the echo is good enough,

sometimes you might go to the cath lab

and get a right in left heart cath or something like that,

or maybe a CTA.

But the better we do, you know, the more this,

the more this is nebulous question mark

or there's a discrepancy,

the more the patient's next step when we're approaching a

severe valve problem is TEE if we can save the patient from

TEE, it's, it's a really nice thing

to not have to do to a patient.

You know, contrast echo isn't

always going to solve the problem.

We have a role for dobutamine, uh, you know,

if we're looking at low flow, low gradient as that, that

that can cause, you know,

some hiccups too in patients dobutamine is not something you

can do in the, in the clinic setting.

Usually that's also hospital

'cause it's, it's, it's, uh, pro arrhythmogenic.

But, um, if you,

if you can save your patient from getting a TEE by dr

by doing a high highly, you know, um,

efficient valve study with the transthoracic, you're,

you're really helping, uh, the patient.

That's a great point. Um,

you know, it's one of the, just to

Add to that too, great Motivation.

Yeah, go ahead.

Yeah. Oh, just to add to that too, we didn't, uh,

go into using contrast much with the aortic stenosis,

but that is, uh, a really great way

to keep the patient from having to have a TEE, uh,

after working in hospitals with structural heart labs,

you know, we used contrast just

for aortic stenosis on a majority of our patients.

So another great option

of making sure you get all your numbers matched.

Yeah, that's a great, uh, great indication

for, uh, contrast.

Yeah. All right, so let's move on

to the next question or comment.

Okay. I can handle that one.

Um, yes, this will be made available@ime.com.

Um, once you go there, uh, to claim your credit.

Um, so that, that will be available. Okay.

We'll move on next. Okay.

So, so somebody said, according to a SES, well,

it should say S prime is,

is abnormal less than 10, not 9.5.

Can you ask comment on that?

Yeah. Um, so that's a great, great thing to bring up.

Um, so it actually changed in 2015.

Um, according to a SC, they actually have a, um,

RV guidelines upload, um, that they posted, uh, from their,

their presentation in Florida.

And in 2010 it was 10,

but in 2015 it changed the 9.5.

Um, so that change happened a couple years ago,

but we could totally see why, you know, uh,

a SC is always updating things, so mm-hmm.

Sometimes it's kind of to keep up with,

with the constant changes.

So that's a great, great point to

Yeah. And we'll have those,

uh, those references

will be available, yeah.

Online. Great. Great point.

Yeah. Yeah, I like that one.

Okay. Um, I'm not sure the context of

what they were talking about.

I think that they were saying on this one, someone said

that unfortunately there's no study, so I'm, I'm, you know,

they're probably talking about literature

or, you know, randomized clinical control studies on, uh,

which way is a correct way to do this.

And this was immediately after the, the comment on the, uh,

a SE abnormal.

Um, I'm not sure, do we know,

does anybody know the context of that one?

Jess and I were trying to figure Yeah, that one out we're,

yeah, we were trip out like the presentation, but

Yeah, so I'm so sorry. Unfortunately,

we, uh, we'll have to move on

to the next question here, comment.

So I'm not sure which, what they specifically were talking

about if, uh, Natalia wants to chime back in, maybe.

Um, so let's move on to that next, uh, uh, question here.

So, um, in the presence of proximal septal hypertrophy,

should the basal LVED diameter be measured more apically

as where you would measure the IVS

or should it still be taken at the base?

So typically you're gonna measure the walls, um,

you'll measure two different measurements, uh,

for the lv.

So you'll be doing the wall measurement,

and then you will move back a little bit

to do your measurement.

But again, this is where biplane is gonna be a lot more

accurate in these cases.

So, you know,

the EF from just the one slice is not going to be accurate.

So we do that measurement typically just

for the wall thickness.

Okay. Thank you. Alright, so final comments.

Um, does it, do any of the, uh, it looks like mm-hmm.

It looks like you're referring to tap C I'm guessing

that's, uh, na that everyone's saying that that's, um, okay.

About the TAP C measurement.

I don't know if that was for the, the angle on the,

Okay. Oh, that,

that, yeah, that might have been,

I think I saw someone was, um, talking about,

so different machines will actually give you different types

of measurements where you're able to, um,

pull your cursor calipers to, so TAPI is a,

a distance measurement.

So some of the machines you'll actually be measuring

straight up and down because that's our only option.

Um, and some of 'em you have the option to go side to side,

and, um, but ultimately it's the same numbers,

it's the distance.

So they're, they're both gonna,

I just see this too, as someone who does multimodality

cardiac imaging, the way the white ventricle is twisted

and shaped echo is not designed to, uh,

look at RV ejection fraction and certain RV measurements.

These are all just, um, sort of like nice, nice to haves,

but at the end of it all, um,

to really get a volumetric measurement on RV structure

and function, you need to do, you know,

originally it was mugga scanning and,

and just move to cardiac mr.

Mm-hmm. And the way the cardiac MR works, it can,

it can really evaluate the right

ventricle really, really well.

And, and clinically in terms of the right ventricle,

you know, there is a guideline that, for example,

if you're going to replace a mitral valve

and put a, a repair and ring on it, when you're going in

and doing cardiac surgery, if the right ventricle

is laterally greater than four uh, centimeters in,

in, um, in, uh, dilation, you go ahead

and you put a tricuspid ring on on it too for a patient

that already has moderate plus tricuspid regurgitation.

But there's, there's, um, you know,

there's a few pathologies

that exist purely on the right side, some carcinoid,

epstein, uh, things like that.

But you know, the, the right side, the right side, you know,

maybe, maybe you might see a pe you know, um, maybe

with some abnormal apical motion,

but right side evaluation, if you're spending a lot

of time on a right side evaluation,

and let's face it, your EF is off on the left side,

you know, uh, it, it, it's not, it's not, um,

you know, I mean, as, as, as someone who deals who dealt

with ICU patients, you know, the, the right at the end

of it all the right heart was just a big low pressure

extension of the IVC.

You know, it's, it's, uh, until it's completely failed,

it's, it's, it's not as critical to get some

of those measurements as it is with the other ones

that we talked about before.

Um, so, you know, if you have limited time, tapi would,

would not be one of the top three things i I would

be worried about on my echo.

Great point. Okay.

That's a good, uh, we'll make this the final question here.

Um, in your opinion,

what is the most common error seen when measuring?

Well, I'd like to hear what everybody has to say

because you all have a different perspective,

but I would say unfortunately, ejection fraction, believe it

or not, unfortunately,

and number two, um, would probably be like, uh, LV

LV wall thickness by, uh, taking in some, um,

a, uh, mitral valve, uh, papillary muscle

or some of the posterior wall papillary muscle attachment.

And basically not, not getting a good delineation of the

myocardium is, and,

and giving somebody a diagnosis of LVH

that they may not actually have.

But I would say unfortunately, the most common error

is still ef.

And, and some of that's just coming from antiquated echo

machines that pump the EF onto the report from the M mode.

Um, some of the ones that we saw where there's just,

you know, not everybody's even doing Simpsons on all the

echoes, but if you're gonna do it, you wanna do it right.

Um, but visually, if you see a 60 to 65%, which is,

you know, the normal range

and you're getting some measurement, that's not that you,

you have to start looking at why.

And there are some other interesting

reasons why that might be.

It could be tachycardia, it could be,

it could be arrhythmia, um,

but always get the, you know,

always get the EF in more than one, uh, view.

You can't just get parasternal lung axis

and say, this is the ef and, and move on

and do some kind of truncated echo.

You've gotta get, my favorite axis is short axis.

'cause then I can see the entire,

every wall squeezing at the same time.

I'm not limited to just two.

Um, so I really like to see that short axis.

So if I had to get one picture that would gimme an ef,

it'd be a, a ba a basal short axis.

'cause I can really see a good,

a good squeeze or lack thereof.

Okay. I think from our end, uh,

definitely agree with that.

But also we see a lot

of tricuspid regurgitation measurements being wrong

or over measured, giving patients pulmonary hypertension

diagnosis and things that aren't really there just

because of errors in the measurement.

A lot of like chasing feathering. Mm-hmm.

Like measurements, like, you know, what, uh, at, at the end,

like how we discussed in the video.

So I think, uh, definitely what Dr. Freeman said.

And then also on our end, we see, uh, quite a bit of that as

Well. And I'll

add one more.

Um, normal diastolic dysfunction when they have pseudo

normal grade two and, and what's the giveaway?

Left atrial enlargement.

Anyone that's had enough pressure

abnormalities in their heart

that their left atrium has enlarged, especially

beyond 4.5 centimeters, they,

there's no way they have normal diastolic dysfunction.

No way. And if you're not doing tissue doppler

and you're simply doing an EA

and it looks normal, it is not normal, it is pseudo normal.

And they've moved past the, uh, reversal EA stage back

to the pseudo normal, which is, which is, uh, the next stage

of diastolic dysfunction.

You know, as it progresses from there on to restrictive,

sometimes there's a giveaway where the,

where the EA ratio is like high, like at two to two

or three beyond just one.

But I see a lot of normal dias dysfunction

with a left atrium of 5.7 and an EF of 45.

No, if your EF is below 50, you do not have diet,

you have abnormal dias dysfunction.

If your eight left atrium is large,

you have abnormal dia dissoc dysfunction.

If you have hypertrophic cardiomyopathy,

you have abnormal dias dysfunction.

If you have an age greater than 65,

you do not have normal diastolic dysfunction anymore.

Extremely rare. Just myocardial stiffening of, of, of, of,

of the elderly.

Not that 65 is so elderly to me anymore,

but, um, there's very few people beyond.

I show me someone with normal diastolic dysfunction

after the age of 65.

I, you know, no, no.

Yep. Common sense there. All right.

Well that was a great, um, great set of, uh,

questions and commentary there.

Um, this should conclude our, uh, our, uh, webinar today.

Um, everybody who, uh, attended,

we're gonna put up the information on where you're going

to need to go to claim your credit.

Um, if you're, um, A-R-D-M-S, um,

a PCA, um, CCI, once you claim

that credit on our website@www.iame.com,

that will automatically transfer over to your,

um, to your CME bank.

Um, uh, so let's go ahead and throw up this slide.

Uh, and I'd like to thank all of our, um,

we're gonna thank all of our, our participants tonight,

um, on our way out.

Uh, thank you so much for joining us, uh, Jessica Huley, uh,

Brittany James, and Dr. Joseph Friedman.

Thank you so much.

Best Practices to Avoid Common Errors in Cardiac Sonography Measurements for 2024

Chapter 1