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 Table of Contents  
FROM THE EDITORíS DESK
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 110-122

History behind development of echocardiography in India


Senior Consultant Cardiologist and Director, Non-Invasive Cardiac Laboratory, Metro Hospital and Heart Institute, New Delhi, India

Date of Web Publication29-Aug-2019

Correspondence Address:
Satish K Parashar
Non-Invasive Cardiac Laboratory, Metro Hospital and Heart Institute, New Delhi - 110 024
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_39_19

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How to cite this article:
Parashar SK. History behind development of echocardiography in India. J Indian Acad Echocardiogr Cardiovasc Imaging 2019;3:110-22

How to cite this URL:
Parashar SK. History behind development of echocardiography in India. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2019 [cited 2019 Nov 13];3:110-22. Available from: http://www.jiaecho.org/text.asp?2019/3/2/110/265754



Tremendous strides have been made in the evolution of echocardiography in India, and as such it is, currently, the most sought after noninvasive diagnostic technique in the field of cardiology. It provides diagnostic and decision making algorithms in a large number of cardiac disorders. The increasing technological advances completely revolutionarized the field of noninvasive cardiac imaging, and echo was rightly projected as the “stethoscope” for cardiologists. The technological advances in India have matched and not lagged behind with Western countries. The aim of the article is to provide an overview of the historical development of echocardiography in this country and to pay tribute to all the pioneers in the field of echocardiography in India, who strived hard to raise it from infancy to the present state. At some stage, many centers were simultaneously involved in projecting new technologies; hence, it may be difficult to know who were the first persons to bring those particular technologies in India.


  The First Appearance of Echocardiography Top


Phase of M-mode echocardiography

As expected, echocardiography made its first presence in the form of M-mode echocardiography. It was a herculean task to get images as it consisted of a small screen and a pen-like transducer which was manipulated “blindly” to get an ice pick, single-dimensional images with no predetermined imaging planes. It was also difficult to align the M-mode perpendicular to the structures which were displayed (i.e., the septum), thus leading to false measurements. One of the earliest M-mode echocardiography machines were installed at Port Trust Hospital, Bombay (now Mumbai) and Army Hospital, Delhi in 1975. However, no useful research or clinical work was initiated due to nonavailability of trained echocardiographers. During that period, the author proceeded to the United Kingdom for higher training in cardiology and echocardiography. During the next 2 years, a more clinical and scientifically oriented echocardiography was initiated in various cities such as K. D. Shah from Bombay, R Alagesan and C Lakshmikanthan from Madras, and self from Delhi. The application of M-mode echo extended much beyond the diagnosis of mitral stenosis and pericardial effusion. As such several congenital and acquired cardiac lesions could be diagnosed. Interestingly enough, some of the DM (cardiology) thesis were restricted to M–mode echocardiograms like in one case “changes in.mitral EF slope before and after mitral valvotomy.”

Those were the days when recordings were obtained on ultraviolet paper in strip chart recorder. The recordings used to fade away if exposed to sunlight. Hence, few useful images were usually wasted. In 1979, Lakshmikanthan took some of the M-mode echo tracings for a DM examination [Figure 1], [Figure 2], [Figure 3]. The examiners were very impressed and suggested to bring out a textbook on M-mode echo. As such, the first textbook was printed in the year 1979–1980 by Lakshmikanthan and Alagesan [Figure 4]. As echo was still in a very infantile stage; hence, few of us presented papers in various conferences to create its awareness in the country and stress on the utility of echo in daily clinical practice. In one of the conferences in Mumbai, in very early eighties, the author presented a paper entitled” M-mode features of inoperable left ventricle (LV) aneurysm,” a subject which may not be relevant now, and this session was chaired by Harvey Feigenbaum.
Figure 1: A case of the left atrial myxoma showing tumor mass within the mitral valve. The bottom image shows tumor mass in the left atrium. RVOT: Right ventricular outflow tract, ARVW: Anterior right ventricular wall, PCG: Phonocardiogram, AMV: Anterior mitral valve, PMV: Posterior mitral valve, IVS: Interventricular septum, PLVW: Posterior left ventricular wall, T: Tumour mass, AV: Aortic valve, CW: Chest wall

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Figure 2: An M-mode recording, during the early phase of M-mode echo, of a case of hypertrophic obstructive cardiomyopathy showing the systolic anterior motion of anterior mitral leaflet with asymmetrical septal hypertrophy interventricular septal. The right-sided tracing shows mid systolic closure of aortic valve (thick arrow). PLVW: Posterior left ventricular wall, AMV: Anterior mitral valve, PMV: Posterior mitral valve, IVS: Interventricular septum, PLVW: Posterior left ventricular wall, LA: Left atrium, AV: Aortic valve, CW: Chest wall, SAM: Systolic anterior motion

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Figure 3: M-mode echo showing both anterior (anterior right ventricular wall) and posterior (posterior left ventricular wall) pericardial effusion (effusion) as an echo-free space. AMV: Anterior mitral valve, PMV: Posterior mitral valve, IVS:Interventricular septum, PLVW: Posterior left ventricular wall, AV: Aortic valve, CW: Chest wall

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Figure 4: The first M-mode textbook of echocardiography from Chennai

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  Two-Dimensional Echocardiography Top


Realizing the limitations of M-mode echo, the next step was the development of two-dimensional (2D) echocardiography which opened a new vista in imaging by visualization of large number of structures not earlier seen by M-mode echo and seeing multiple structures simultaneously in an imaging plane. This led to more increasing clinical applications because of the visualization of hitherto nonvisualized structures from various scan planes. A large number of congenital and acquired cardiac lesions and their complications could be seen. One of the first 2D machines (Advanced Technological Laboratory - ATL) was procured by G. Vijayaraghavan in the late seventies in Medical College, Trivandrum [Figure 5]. To increase awareness, various workshops were organized by ATL/Indchem laboratories. As Kerala was a center for endomyocardial fibrosis (EMF) so Vijayaraghavan et al. did an extensive work on EMF which was nationally and internationally recognized and presented in various international conferences. It would be interesting to see the 2D images of that era [Figure 6] and [Figure 7] during 1980–1981, 2D-echo equipment was bought in Army Hospital, Delhi and Madras Medical College, but the limitation was of getting good 2D images was due to the presence of linear array transducer system. Over a period, various echo companies, especially Hewlett Packard, started marketing first phased array 2D-echo machines and practically every major hospital in India, by 1984, had a 2D-echo machine installed. The main limitation, at this stage, was that the equipment provided only anatomical and functional information, but hemodynamic information was lacking. As such invasive studies were performed in every case, including valvular and common acyanotic congenital cardiac lesions, to get a complete diagnosis and quantitation. As the quality of equipment improved, so did the 2D-imaging quality [Figure 8], [Figure 9], [Figure 10].
Figure 5: First two-dimensional echo machine installed in Vijayraghavan's unit in Kerala

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Figure 6: The initial quality of two-dimensional echo imaging. A right atrial thrombus in a case of tropical endomyocardial fibrosis

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Figure 7: Peripheral venous contrast echo in a patient with patent foramen ovale and right to left shunt in tropical endomyocardial fibrosis: Era of late seventies

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Figure 8: A two-dimensional picture of the left atrial myxoma with superimposed infective endocarditis leading to perforation of anterior mitral leaflet (arrow). LV: Left ventricle, MV: Mitral valve, LA: Left atrium showing tumor mass endocarditis leading to perforation of anterior mitral leaflet (arrow). LV: Left ventricle, MV: Mitral valve, LA: Left atrium showing tumor mass

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Figure 9: A case of acute pulmonary embolism with saddle-shaped thrombus at pulmonary artery bifurcation (arrow). PA: Pulmonary artery

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Figure 10: (a) Venous contrast echo during M-mode era (see text for details): RV: right ventricle, LV: left ventricle, MV: mitral tunnel. (b) Short axis view. Peripheral venous contrast echo in a case of patent ductus arteriosus with reversal of shunt showing opacification of descending aorta

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An exciting development of peripheral venous contrast echocardiography was first initiated by the author in 1977, which facilitated the diagnosis of right to left intracardiac shunts. One of the few criteria to diagnose right to left ventricular septal defect (VSD) and atrial septal defect (ASD) flows, on venous contrast echo [Figure 10], was to see the venous contrast pattern in mitral tunnel (area bound by mitral leaflets). In VSD (left panel), there is no opacification of mitral tunnel, indicating that contrast has bypassed the mitral tunnel/leaflets) due to R-L VSD flow. On the other hand, in ASD (right panel) the flow is from the left atrium-right atrium-left ventricle (LA-RA-LV) thereby opacifying the mitral tunnel.

Despite the era of several technological advances, this technique is still being used in clinical echocardiography.


  Conventional Doppler Echocardiography Top


In view of limitation mentioned above about inability to achieve hemodynamic information, Doppler echocardiography appeared on the scene in India in mid-eighties. This came simultaneously in all major hospitals in India. However, in the early systems, the blood flow pattern could not be visualized in conventional Doppler; hence, it was a time-consuming process to get parallel to blood flow to get maximum velocity. This was the main limitation in the study. Moreover, the Doppler systems were not well developed to provide useful information. Some of the equipment did not have continuous wave Doppler which records high velocity diseased flows. As such Doppler studies remained inconclusive up to early and mid-eighties in our country.


  Color Doppler Echocardiography Top


During 1984–1985, there were significant publications, in international literature, of this fascinating technology and was considered as a major breakthrough in cardiovascular ultrasound. This technological development involved direct visualization of blood flow on an overlay 2D-echo image. As such one could directly visualize the blood flow and hence place Doppler beam parallel to it thereby getting an ideal blood velocity and thus hemodynamic information. This technology was the work of Omoto et al. in Japan, who was a cardiac surgeon, and Aloka was one of the first companies to produce color Doppler equipment. In 1984, it was first introduced in the United States of America (USA), as a clinical tool, by Navin C Nanda at University of Alabama in Birmingham. Our group, in Mool Chand K. R. Hospital, for the 1st time in 1985, organized a National Workshop on Color Doppler Echocardiography and Thrombolytic Therapy in Delhi under the guidance of Navin C Nanda who was a leader in this field. It was held in Hotel Ashok. This was a big teaching experience for all participants. That was the period when no live demonstrations were possible in the venue. This was because the concept of live demonstrations was not there at that time, and second, there was paucity of large echo machines which could not be transported to the venue. As such, it used to be mostly lectures. However, in this particular conference, batches of 20 delegates were brought to the echo laboratory of the hospital to see live echo. It was a fascinating experience for delegates who had never seen live echo images before. It was a herculean task to ask one batch to leave so that the next batch could be accommodated. It was an experience to see delegates piling on each other in a small echo lab. Subsequently, similar workshops were organized in different cities of India where Navin Nanda, Natesa Pandian, and Bijoy Khandheria conducted hemodynamic, and Color flow mapping workshops. This led to the widespread awareness of this technology. During 1986–1987, several centers in India, including ours, were actively involved in the use of this technology and providing more complete hemodynamic information. Several continuing medical education (CME) programs were conducted by national icons in this field all over the country. With the help of this technology, Anjaneyulu et al. were the first persons in the country to study coronary arteries by transthoracic echo (TTE). They evaluated the left main coronary artery stenosis by TTE and studied its correlation with coronary angiography. They demonstrated a sensitivity of 85% and positive predictive value of 82.5%. This work was published in the Journal of American Society of Echocardiography. To honor Navin C Nanda, Natesa G Pandian, and Bijoy Khandheria for their untiring efforts in initially promoting echo in India, three orations were initiated in the scientific sessions of the Indian Academy of Echocardiography (IAE). Nanda oration is usually delivered by an international icon, Khandheria oration by the President of the academy and Pandian oration by the past President's by rotation.


  Indian Academy of Echocardiography Top


How the concept was formed?

During the late 1980s and early 1990s, echocardiography was restricted to very few individuals only, and there was a lack of awareness and realization of its importance in cardiovascular medicine. In various cardiology conferences, the smallest hall was given to echo sessions as the audience consisted of presenters, their two supporters and few senior echo people. We used to run to collect chairpersons. At the same time, that was the period when young cardiologists and physicians were realizing the potential of echo and wanted training in this specialty. However, there was no forum where this facility could be provided. Hence, it was felt that there should be a forum to disseminate the knowledge of echocardiography in the country and encourage training and research in this field. Realizing the above facts, and to promote echocardiography in India on a scientific basis, some of us felt that there was a dire necessity to form a society dedicated to echocardiography.

When was Indian Academy of Echocardiography formed?

Although the proposal to form IAE was mooted much earlier, in December 1994, during the Annual Conference of Cardiological Society of India (CSI) at Chennai, in Hotel Park Sheraton, 10 individuals including two interventional cardiologists had a meeting, in a small available storeroom, and the concept of IAE was proposed. This was accepted, and it was stressed that one of the main objectives of the Academy should be to have academic activities and create widespread awareness of echo. Savitri Shrivastava was proposed as the President and (Col) S. K. Parashar as the Secretary which was accepted, and an executive committee was formed. It was also stressed that like few other societies, the IAE should not “die a premature death” and collective efforts will be made to make it a very healthy and viable academy. As such, it has now reached a stage that it is the largest society in subspecialty of cardiology with more than 2700 members and 12 state chapters who are doing very useful academic work.

Why the name academy and not society?

In 1985, four individuals in Delhi, including a reputed international icon of Indian origin, formed an Indian Society of Echocardiography and got registered in that name. For some obvious reasons, no other important persons were involved in this society. No attempt was made to popularize it. As such society continued to have only those four members, and it never took off and died a “premature death” hence the name academy had to be chosen.

How the logo was conceived?

During the V th Annual Conference of IAE at R. N. T. Medical College, Udaipur, organized by S. K. Kaushik, a very magnified view of a “Rangoli” (a decoration made with flowers and other articles), was put near the main entrance of the conference hall. This was conceived and prepared by Dr. Ravi Gupta, a young resident doctor of this medical college and now a reputed interventional cardiologist. It was highly appreciated both by the delegates and the foreign faculty, especially Itzhak Kronzon. Dr. Gupta was requested to design it as an IAE logo on the same pattern which he did so. He was awarded a “princely sum” of Rs. 1000/- for his efforts.

Daily running of Indian Academy of Echocardiography affairs

During the initial period of IAE formation, there were no advanced computerization facilities, and due to financial constraints, no office or any form of secretarial support was available. This is because during that period, the only source of finances was the membership fee. As such, the daily time between 6.00 pm and 7.00 pm was designated as “IAE time” in the author's home. The whole family assembled, and duties were assigned. One filled up the membership register; others looked after the accounting and making receipts of money received third wrote addresses on various envelopes to be posted and the fourth pasted stamps on these envelopes. Other duties were also shared. The main aim of this exercise was that IAE functioned efficiently, and the members do not get dissatisfied due to lack of communication.

Academic activities of the Indian Academy of Echocardiography

In February 1995, the 1st Annual Conference of IAE was held for 1.5 days only at Hotel Le Meridien, New Delhi, India. This was attended by 93 delegates only because the organizers could not afford more than 100 delegates to attend due to financial constraints. The total collection of funds was Rs. 75,000 (with the current exchange rate it is about $ 1500) and expense of the conference was about Rs. 50,000/(712 USD) with a saving of Rs. 25000/. With the balance money left, it was decided to initiate a Journal of IAE (JIAE).

The IAE expanded further, and subsequently, regular annual conferences were held in different metropolitan cities in every meeting select international faculty was invited. In the early phases, Nanda, Pandian and Khandheria played a significant role with their participation. Over the years, there was a progressive increase in delegate numbers and international faculty in 2019 the Silver Jubilee Meeting is being organized in a big way. In every conference, special sessions are organized for technicians/cardiac sonographers who are doing a commendable job in daily clinical practice.

Guidelines published by the Indian Academy of Echocardiography

The IAE, as per its aim of propagating academic activity, has published three guidelines- (a) IAE performance standards and recommendations for a comprehensive transthoracic echocardiographic study in adults, (b) IAE guidelines and manual for the performance of stress echocardiography in coronary artery disease and (c) the IAE practice guideline for the performance of transesophageal echocardiographic evaluation of a patient with cerebrovascular stroke. These have been mainly due to the tremendous efforts of Nitin Burkule, Manish Bansal, Rahul Mehrotra, Satish Govind and S Sola These guidelines have been published in JIAE in 2017 and 2018.

International recognition of the Indian Academy of Echocardiography

In the year 2000, we successfully bid for VI th World Congress of Echocardiography and Vascular Ultrasound. This was held from February 8 to 10, 2002, at Hotel Ashok, New Delhi, with Naresh Trehan as President and Satish Parashar as Secretary-General. There were 87 international participants from 33 countries. There were 49 international faculties with 25 faculties from the USA [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]. There were few interesting anecdotes during this World Congress: (a) one night before the conference, at about 10.30 pm; we were called by Tajik to get another large-sized projection screen made besides the auditorium screen. This was because he wanted to show “advances in echocardiography” which was an excellent audiovisual presentation prepared by Mayo Clinic IT Department. He also did not want any joining of two screens. Ultimately, the audiovisual persons got it ready by about 2 am and approved by Tajik at 6 am (b) Julius Gardin, due to possibly his Israeli background and religious belief, during the conference period, would not touch mike or pointer during his lecture nor travel by car. During his lecture, we dedicated an audiovisual person to handle this problem. This was a mistake done by us of getting a nonmedical person to help him because when he wanted to focus on mitral valve, the audiovisual person would point to another structure like tricuspid valve. Then, one of the organizers took over this job, and the presentation went on smoothly. His inability to use a car made him and his son walk all the way from Hotel Ashok to Hotel Taj Palace where fellowship function and dinner was held. To ensure his late-night safety, being a foreigner, two individuals were requested to accompany them back to Hotel Ashok (c) One faculty from Moscow, who did not inform about his travel plans, landed at Hotel Ashok Yatri Niwas (a very low budget hotel) instead of Hotel Ashok. This could have been possible as the cab driver, seeing his crumpled shirt and torn jean (possibly a fashion) took him to that hotel. This all happened due to language problem. Finally, after repeatedly saying “Ashok” he was sent to the conference hotel (d) one faculty landed in late evening without a visa. He was denied entry. However, he did a commendable job by going back to a nearest Asian country, got a visa and came back.
Figure 11: Inaugural function of World Congress 2002

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Figure 12: Naresh Trehan, National President, lighting the lamp during inauguration

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Figure 13: Satish K Parashar, Secretary-General, lighting the lamp. Other dignitaries present include, Health Minister – Thakur, Navin C Nanda, H. K. Chopra, P Krishnam Raju, J. C. Mohan, partly seen Ravi Kasliwal

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Figure 14: Abdul Jamil Tajik, one of the greatest doyen in the field of echocardiography receiving a memento

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Figure 15: Fellowship function during World Congress

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Figure 16: An international delegate receiving memento from Navin C Nanda, Naresh Trehan and Ravi Kasliwal

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Figure 17: James Thomas receiving memento from R. Alagesan

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Figure 18: A section of the delegates at the World Congress

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It was a highly successful and much appreciated Congress and formed the step for international fraternity to recognize IAE. Subsequently, our aim was to get some simultaneous recognition from the American Society of Echocardiography (ASE) and European Association of Echocardiography (EAE), later known as European Association of CardioVascular Imaging (EACVI). Some of us used to attend ASE scientific sessions and the first leadership meeting was held in 2006 when Prof. Michael Picard was President of ASE. However, nothing fruitful emerged. The real breakthrough occurred during 2008–2009. In February 2008, the X111th International Conference of Clinical Echocardiography and Annual Conference of IAE was held in Delhi. This was attended by Roberto Lang, who conducted a 3D-echo workshop. He was impressed with the quality of the conference and luckily was the President-Elect of ASE. In 2009, during one of the American College of Cardiology scientific sessions, the author had a short meeting with William Zoghbi, then President of ASE, together with Roberto Lang. At that time, it was decided to have an academic collaboration between two societies, and an alliance was formed. Over a period due to the excellent quality of presentation by IAE faculty in ASE meetings and our continued efforts of holding leadership meetings, the alliance was further strengthened. As a result of this, a joint academic session between the two societies became a regular feature in the Annual Conference of IAE. In most of the meetings, the Presidents of ASE and other top leaders have been attending.

EAE: In the World Congress of 2002, Alan Fraser (later to become President of EAE) was an invitee. In 2004, some of us met Fausto Pinto, then President of EAE (now EACVI) and Alan Fraser during Annual Scientific Sessions of EAE and a casual preliminary discussion on the academic alliance was discussed. However, nothing concrete came out. The period 2006–2010 was very fruitful for academic alliance between the two societies. This was the period when the Presidents of EAE were Petros Nihoyannopoulos and Jose Zamarano – a real friend of IAE. During this period, besides few other societies, a one hour session on case studies was given to IAE, and many of us regularly presented cases in their meetings. Due to some financial constraints, these sessions were abandoned after few years, but joint academic session between the two societies has continued in annual scientific sessions of EACVI and IAE.

The IAE now has a universal appeal. In 2017, an academic alliance was developed with Asian Pacific Association of Echocardiography headed by Jae Oh. As such, with the efforts of every member of IAE, the academy has established its academic strength globally.

Very successful World Congress has also been organized in 2011 and 2017 at Delhi and Jaipur respectively [Figure 19], [Figure 20], [Figure 21], [Figure 22] with self as National President and Rakesh Gupta as Secretary-General.
Figure 19: Inauguration of World congress of Echo 2017

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Figure 20: A glimpse of faculty dinner at the Palace of Maharaja of Jaipur. Comments of foreign faculty were that this was the best faculty dinner they had ever attended

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Figure 21: Faculty dinner 2017 with enjoyable dance by international faculty

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Figure 22: One can see Jae Oh, Allan Klein, Sunil Mankad, and other faculties

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  Concept of Preconference CME Top


During the annual conference of IAE at Kochi in 2009, self, Dr's Alagesan and Sameer Shrivastava were sitting in the lobby of the hotel, when suddenly this idea was put forward to both of them, and they readily agreed believing that it would prove to be a very popular concept. The format was decided there itself and was first implemented in the conference at Goa in 2010. Luckily, this has been the most appreciated and widely attended CME. This has now become a routine event in every conference. Since 2017, international faculty has also been involved as an expert critique of various sessions. This is a practically oriented CME with live demonstrations on selected topics.


  Life Time Achievement Award Top


This award was initiated by IAE to honor those members of IAE who had done a commendable job in promoting IAE including its academic activity. This award was started in 2014 during X1X International Conference of IAE held at Goa. The recipients of this award have been self, G Vijayaraghavan, R. Alagesan, R. Manjuran, Ravi Kasliwal, and P Krishnam Raju.


  Journal of Indian Academy of Echocardiography Top


The JIAE was launched in August 1995 following the first Annual Conference held in Delhi. This was possible due to the paltry money saved during the conference. Three issues were brought in a year. That was the period when the journal contained only common review articles for the benefit of budding echocardiographers and postgraduates. The printing cost at that time was almost Rs. 25,000 per issue. Due to paucity of funds, there was one interesting anecdote of that period. To save as much money as possible, the author, together with one attendant, distributed the journal locally on his two-wheeler. To avoid embarrassment, the two-wheeler was parked a little distance beyond the respective residences and attendant used to deliver the journal on foot. This saved the courier cost of about 50 journals. Over a period of time, the quality of the journal improved. The credit of significantly upgrading the quality and scientific content of JIAE goes to untiring efforts of Satish Govind, current Chief Editor of JIAE. He has modified the title to “JIAE and cardiovascular imaging” It is now published by Wolters Kluwer India Pvt. Ltd.


  The Dawn of Myocardial Contrast Echocardiography Top


During the period up to 2004 in India, venous saline contrast echo was being used for delineation of intracardiac shunts and other congenital cardiac lesions. However, due to the large-sized microbubbles produced by agitated saline, they were destroyed in pulmonary circulation and hence left-sided structures were not visualized unless there was right to left intracardiac shunt because of bypassing of saline microbubbles from the pulmonary circulation. However, internationally in late 1980s, some contrast agents were developed which could bypass the pulmonary circulation thereby opacifying LV. These agents consisted of microbubbles of encapsulated high-molecular-weight gas. The application and significant benefits of this technique are well-known. Two echocardiographic contrast agents namely Definity and Sonovue were introduced in the Indian market in the year 2004–2005. Nitin Burkule and his team of Rishikesh Shah at Asian Heart Institute, Mumbai and later at Jupiter Hospital, Thane, were the first adopters of this echo enhancing new modality in India and they worked hard to popularize it throughout the country. Philips Medical System played a significant role in this endeavor. Burkule et al. gave many live demonstrations of the use of contrast throughout the country and trained many echocardiographers in performance of contrast echocardiography. Its value in ischemic heart disease, stress echocardiography, myocardial viability, evaluation of cardiac masses, and in therapeutic interventions such as alcohol septal ablation in hypertrophic obstructive cardiomyopathy were highlighted. Now, this technology is being employed in several centers in the country. However, it is limited to few centers only possible because of high cost of contrast agents and lack of training.

Since 2007 Burkule et al., at Jupiter Hospital echocardiography laboratory are performing the largest number of contrast stress echocardiography studies in India. The experience of their use of contrast echocardiography in various clinical situations was summarized in the textbook chapters and the IAE guidelines for performance of stress echocardiography. Some of the benefits of contrast studies are shown in [Figure 23], [Figure 24], [Figure 25], [Figure 26].
Figure 23: The impact of the left ventricle contrast opacification on improving the image quality in suboptimal transthoracic echo images as seen in the left panel. left ventricle endocardium is well-visualized after contrast injection

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Figure 24: The left ventricle contrast opacification improves the perception of regional wall motion abnormality in stress echocardiography. The left-hand panel shows resting end-systolic frames and the right-hand panel shows peak exercise end-systolic frames. There is distinct akinesia in the left anterior descending territory with left ventricle dilatation at peak exercise

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Figure 25: The low-dose dobutamine stress echocardiography shows biphasic contractile response suggestive of viable and ischemic myocardium. The left ventricle contrast opacification improves the perception of subtle myocardial systolic thickening (contrast echo images contributed by Nitin Burkule)

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Figure 26: The low-dose dobutamine stress echocardiography shows no contractile response (highlighted) suggestive of nonviable myocardium. The left ventricle contrast opacification improves the perception of absent myocardial systolic thickening

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  Three-Dimensional Echocardiography Top


Many cardiac structures are 3D; hence, a limitation of 2D imaging was to image such structures. As such, there was always a quest to develop 3D echocardiography. The earlier 3D-technology had certain limitations such as imaging artifacts due to various technical reasons such as longer time needed in acquisition of images, effect of heart rate, and patient motion during the test. With lot of international literature on 3D-echo, the impetus was felt in India in early part of the century with lot of awareness of this technology, leading to various cardiac centers adopting it. However, earlier studies performed at Escorts Heart Institute, Delhi, India, in some instances, required manual or mechanical rotation of transducer and offline 3D reconstruction to visualize 3D images (TomTec). The developments in modern real-time 3D-echocardiography or 4D-echocardiography, together with color Doppler imaging, began later on with the development of matrix array transducer. The goals and strategies recommended by future of cardiac think tank in major cardiac institutions of India, responded and came out with purchase of these advanced 4D-echocardiographic equipment and there was a spate of publications on 3D-echocardiography with the first book published by Amuthan et al. [Figure 27] who did an extensive work in this technology. There are numerous applications of 4D-echocardiography in clinical practice [Figure 28]a and [Figure 28]b. However, few of them include: (a) the evaluation of cardiac chamber volumes and mass, which avoids geometric assumptions and has a good correlation with magnetic resonance imaging (MRI). Currently, the advances allow the acquisition of single beat; full volume data set rather than several cardiac cycles with improved spatial and temporal resolution (b) the assessment of regional LV wall motion and quantification of systolic dyssynchrony (c) presentation of realistic views of heart valves and chambers which is essential for cardiac interventions including device closure of cardiac shunts, occlusion of the left atrial appendage, etc. It is an ideal modality to study mitral valve and is of significant value in guiding the clinician and surgeon in preoperative decision making, visualizing paravalvular leak in mechanical valves (d) volumetric evaluation of regurgitant lesions and shunts with 3D-color Doppler imaging, evaluation of the severity of regurgitant lesions by evaluating 3D-vena contracta. (e) 3D-echocardiographic stress imaging and many more.
Figure 27: First published manual on three-dimensional echocardiography

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Figure 28: (a) Calculation of left ventricle, left ventricle volume based on heart model concept. (b) Calculation of the right ventricle volume by three-dimensional echo

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  Tissue Doppler Imaging and Speckle Tracking Top


Tissue Doppler imaging (TDI) made its appearance between 1997 and 2000 in numerous echo laboratories in India. Initially, it was being used to assess subclinical LV systolic dysfunction by evaluating and assessing individual myocardial segments and annular velocities with less awareness of diastolic function. However, following the first World Congress, in which there were several lectures on diastology, its role was extended to this field. Still realizing its limitations, speckle tracking echocardiography (STE), was developed as an extension of TDI, which was a new and promising, validated technique which enabled highly reproducible, angle-independent assessment of regional and global LV systolic function in longitudinal, circumferential and radial planes. Longitudinal strain, which denotes shortening of the LV along its long-axis and which is predominantly governed by the subendocardial fibers, was most sensitive and reproducible. Manivasagam et al. from Trichy were one of the first workers in this field for almost a decade and that too in a village surrounding. Due to the cost of equipment, lack of training, the progress was slow. However, with every conference having a workshop on STE, this technology really picked up over the last few years and is widely available now.

It also gave the concept of LV rotation and twist. When viewed from the apex, the apex rotates in anticlockwise direction during systole whereas the based rotates in the clockwise direction. This opposite rotation of the LV apex and base during systole produces a wringing motion or twist of the LV which is critical to the normal systolic functioning of the LV. This rotational displacement is expressed in degrees. LV twist is the absolute apex-to-base difference in LV rotation referred to as the net angle (also expressed in degrees). STE has enabled evaluation of LV rotational and torsional dynamics, various aspects of LV function that were exclusively analyzed by MRI before the introduction of this technique. This fast, widely available technique contributed to a more rapid introduction of LV torsion as a clinical tool for the detection of myocardial dysfunction [Figure 29], [Figure 30], [Figure 31]. As such, it has gained acceptance in several cardiac centers in India. However, like any technology, there are still limitations in technique, interpretation, intervendor variability, reproducibility, and studying patients in nonsinus rhythm.
Figure 29: Illustrates the left ventricular rotation from apical and basal cross-sections of left ventricle obtained by speckle tracking of B-mode cardiac ultrasound images in a normal healthy patient (a) and a case of anterior myocardial infarction (b). (c) Represents a patient with restrictive cardiomyopathy (Amyloidosis) where the net left ventricle twist angle is preserved (images contributed by V. Amuthan)

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Figure 30: Automatic functional image Bull's eye plot of longitudinal peak systolic strain recorded from (a) A normal healthy individual (b) A patient with anterior myocardial infarction and left ventricle apical aneurysm and (c) A patient with amyloidosis with preserved strain in the left ventricle apex giving the classical “Cherry on Cream” appearance

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Figure 31: Another case of amyloidosis showing both parasternal long axis and apical 4 CH views

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  Pediatric Echocardiography Top


The dedicated pediatric echo was in a relatively nascent stage till late seventies and was mainly done by adult echocardiographers. During this period, balloon septostomy, in cases of transposition of great arteries, was being done under fluoroscopic control. The credit for initiating a dedicated pediatric echo program, at All India Institute of Medical Sciences, Delhi, goes to the team of Savitri Shrivastava, which included S. Radhakrishnan, Anita Saxena, S. S. Kothari and few others. This was the period between 1981 and 1984. In the year 1984 or so, pediatric interventions took a positive shape at the All India Institute of Medical Sciences, New Delhi. With the appearance on the scene of trained pediatric cardiologists, pediatric echocardiography and interventions showed significant progress. Hema Rane and Bharat Dalvi from Mumbai, Krishna Kumar from Kochi, I. B. Vijayalakshmi from Bengaluru and many others took this specialty to greater heights. It may be worth mentioning here that Dr. Dalvi spent almost 40 weeks end to promote it all over Maharashtra. A large number of pediatric intervention procedures are now possible under echo guidance.

These have been made possible because of progressive improvement in transesophageal technology Single plane transesophageal echocardiography (TEE) started at Escorts Heart Institute in 1989, Biplane in 1991 and multiplane TEE in 1993. Their initial experiences were published in Indian Heart Journal in 1994. The 3D-TEE has been a great advancement and is now practically available in major cardiac centers in India since the past 6–7 years As such there has been significant progress, in nonsurgical intervention procedures, in various congenital and acquired cardiac lesions [Figure 32]. Advanced interventional procedures have now been made available.
Figure 32: A three-dimensional transesophageal echocardiography in a case of balloon mitral valvuloplasty

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  Progress in Teaching and Training in Echocardiography Top


No progress in any field of medicine is possible without adequate teaching and training. The initial impetus of teaching by live demonstrations and conducting workshops was provided, throughout the country by earlier national stalwarts in echo. Three international icons of Indian origin, namely Navin C Nanda, Natesa G Pandian, and Bijoy Khandheria, but spearheaded by Nanda, conducted teaching sessions at most major and second and even three-tier cities in India practically every year and often many times in 1 year. The teachings included all aspects of adult, pediatric, fetal echocardiography, and also peripheral ultrasound, followed by newer advances and developments in echocardiography such as 3D-echo, myocardial contrast echocardiography, and strain imaging. The IAE played a big part in organizing conferences and teaching workshops. Many of the IAE stalwarts enhanced teaching standards by contributing in bringing out textbooks of echocardiography [Figure 33], [Figure 34], [Figure 35], [Figure 36].
Figure 33: A practical approach of clinical echocardiography

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Figure 34: Applied echocardiography in coronary artery disease

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Figure 35: A comprehensive book for beginners

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Figure 36: Echocardiography in clinical rheumatic valvular heart disease

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Subsequently, as part of its academic activities IAE published its first Text Book of Echo in 2017, contributed by many members of IAE, though edited by V. Amuthan and Satish K Parashar [Figure 37]. A text book of “Advances in Clinical Cardiovascular Imaging Echocardiography and Interventions – Edited by H. K. Chopra, Navin C Nanda, and Jagat Narula was released in 2019. All these books have been very much appreciated. In all released Cardiac Updates, several chapters on echo are being contributed.
Figure 37: First Indian Academy of Echocardiography textbook of echocardiography

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One of the prerequisites of successful echo learning is a personal hands-on training rather than only lectures and workshops. In this regard, JROP Institute of Echocardiography has emerged as one of the finest training institutes both in this and surrounding countries. This training program was conceived in the year 2000 by some of us, but Rakesh Gupta was given the responsibility of organizing regular basic comprehensive and advanced skill training courses, which he has been doing very successfully with great dedication. Short courses on TEE, 3D-echo, strain imaging, and vascular ultrasound are also being organized. Now, a Fellowship in Health Sciences: Clinical Echocardiography in collaboration with Annamalai University, Tamil Nadu has been established. In a nutshell, JROP Institute is a unique institution which has stood the test of time as a training center in echocardiography and has trained several thousand doctors, in the past 20 years, who are doing a commendable job.


  Conclusion Top


This brief summary would help the readers in appreciating the fast-paced developments occurring in this country in the field of echocardiography and how much IAE has contributed to the growth of echo in India. The history of IAE from infancy to the present state of jubilee year is fascinating. This has been made possible due to the great efforts of all colleagues who have always kept IAE above self. It is turning out to be one of the best echo societies in Asia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32], [Figure 33], [Figure 34], [Figure 35], [Figure 36], [Figure 37]



 

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