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  Most popular articles (Since March 23, 2017)

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How to assess mitral stenosis by echo - A step-by-step approach
Gnanavelu Ganesan
September-December 2017, 1(3):197-205
Rheumatic mitral stenosis is the commonest valvular heart disease in developing countries. Other causes include congenital abnormalities and degenerative mitral valve disease. Mitral stenosis when it is due to rheumatic process, can be managed by percutaneous transvenous mitral commissurotomy. Echocardiography remains the most important investigation in diagnosing and planning the managemnt of mitral stenosis. This review highlights stepwise approach for comprehensive assessment of mitral stenosis by echocardiography.
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Doppler evaluation of hepatic vein flow
Sita Ram Mittal
January-April 2018, 2(1):53-66
Hepatic vein (HV) flow pattern closely correlates with pressure changes in the right atrium. Normally, there are two forward flow waves – systolic and diastolic. Diastolic wave is slightly smaller than systolic wave. Three reversal waves can be seen – late systolic, mid-diastolic, and third during right atrial contraction. Normally, forward wave velocities increase during inspiration. Reversal waves are slightly more prominent during expiration. Systolic wave is diminished in atrial fibrillation, right ventricular systolic dysfunction, and tricuspid regurgitation. When these pathologies are severe or they coexist, systolic wave may reverse. Diastolic wave is diminished in tricuspid stenosis and impaired relaxation of the right ventricle as seen in right ventricular hypertrophy, right ventricular ischemia, or infarction. Diastolic flow reversal wave becomes prominent in restrictive cardiomyopathy and pericardial constriction. Reversal wave during right atrial contraction is absent in atrial fibrillation. It is diminished or absent when compliance of HVs is decreased due to diseases of liver parenchyma. This reversal wave is prominent in each cardiac cycle in tricuspid stenosis with sinus rhythm and in patients with right ventricular hypertrophy. It is intermittently prominent in the presence of ventricular ectopics and complete atrioventricular block.
  10,367 1,485 1
Speckle tracking strain echocardiography: What sonographers need to know!
Ashlee M Davis, David Adams, Ashwin Venkateshvaran, Fawaz Alenezi
May-August 2017, 1(2):133-139
Introduction: Strain is a unitless measurement of dimensional or deformational change; speckle-tracking echocardiography is the most widely used technique to assess strain, with demonstrated clinical utility in a variety of settings. Objectives: This paper reviews the diagnostic and prognostic impact of echocardiographic assessment of left ventricle myocardial strain and what sonographers need to know in a daily practice. Methods: This paper have the most updated American society of echocardiography recommendations on a speckle tracking strain echocardiography, and included experiences of a large academic center, standardization as well as tips needed to perform a strain in a daily clinical practice. Conclusion: With good feasibility, reproducibility and evidence in support, speckle tracking strain echocardiography can be used as a standard echocardiography parameter in clinical practice.
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Fetal echocardiography: A systematic approach
Atul Karande, Shweta Nagar
January-April 2017, 1(1):47-54
Congenital heart disease (CHD) is the most common birth defect worldwide. The optimal timing for performance of a comprehensive transabdominal fetal echocardiogram is 18–22 weeks gestation. All radiologists should perform screening of the heart during all obstetrical ultrasound studies beyond 18 weeks of gestation. Detailed fetal echocardiography can be performed only with the help of a technically well-quipped ultrasound machine. Skilled expertise and appropriate knowledge are required to perform detailed fetal echocardiography. Despite of limitations, fetal echocardiography can identify most of the CHDs which have major pre- and post-natal implications. This is necessary to delineate the high-risk group of fetuses who are suffering from complex cardiac defects and would require tertiary hospital setup for delivery. This further aids in appropriate postnatal medical as well as surgical management, antenatal parent counseling, and explaining risk factors as well as postnatal outcome.
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Indian academy of echocardiography performance standards and recommendations for a comprehensive transthoracic echocardiographic study in adults
Nitin Burkule, Manish Bansal, Rahul Mehrotra, Ashwin Venkateshvaran
January-April 2017, 1(1):1-17
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Echocardiographic evaluation of pulmonary hypertension
Rajesh Krishnachandra Shah
May-August 2018, 2(2):95-105
Pulmonary hypertension (PH) is the end result of nearly all cardiac and some noncardiac conditions. It is an important marker of mortality and morbidity. It is also the deciding factor in the management of the etiological conditions, such as the timing of surgery in valvular heart disease, follow-up of pulmonary arterial hypertension, diuretic therapy for diastolic dysfunction, and so on. To add to the problems, early signs and symptoms are nonspecific, and so the diagnosis is attained at a later and advanced stage. Although clinical evaluation is always essential, echocardiography is now the main tool for the evaluation of PH. The aims of echocardiography in PH are: (1) to identify the etiology, (2) assess the effects of PH on the right ventricle, (3) estimation of the severity of the PH, (4) monitoring the progression and therapeutic response in PH, and finally (5) predicting the prognosis. It is hence very important that one measures the pulmonary pressures accurately for proper patient management. The aim of this article is to provide a detailed information of the different parameters of PH in the different echocardiographic views and the technique of measuring these parameters.
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Essential ergonomics to minimize work-related musculoskeletal disorders in echocardiography
Shantanu Deb, Ashwin Venkateshvaran
January-April 2018, 2(1):49-52
Physicians and sonographers performing echocardiographic scans place themselves at risk of developing work-related musculoskeletal disorders (WRMSDs) owing to faulty posture and repetitive hand and arm movements. Poor ultrasound ergonomics plays a pivotal role in the development of WRMSD and can result in injury and sickness absence, impacting efficiency and work productivity. The aim of this article is to draw the attention to common considerations and corrective measures to reduce the risk of WRMSD among professionals actively performing echocardiographic scans.
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Echocardiographic assessment of diastolic function
Aniruddha De
September-December 2017, 1(3):214-221
The stepwise approach in evaluation of left ventricular (LV) diastolic function is essential in any patients with dyspnea on exertion or heart failure. Many of them have normal to near-normal ejection fractions (EFs). These subsets of patients are labeled as diastolic heart failure or heart failure with preserved EF. It is important to differentiate diastolic dysfunction from dyspnea of pulmonary origin for further management and future prognosis. LV filling pressures is usually synonymous with pulmonary capillary wedge pressure (PCWP), mean left atrial pressure (LAP), mean LV diastolic pressure, and LV end-diastolic pressure (LVEDP). PCWP on the other hand is also an indirect estimate of LV diastolic pressures. LVEDP is often elevated in early diastolic dysfunction because of a large atrial pressure wave, while mean PCWP and LAP remain normal. While mean PCWP and LAP increased during tachycardia and where there is increased LV afterload which is the basis for the diastolic stress test. It is essential that certain Doppler variables correlate well with an increase in LVEDP only and not reflecting the increase in either LAP or LVEDP. Therefore, early evaluation of LV filling pressures and LVEDP are more important than mean LA pressure which is elevated later. Echocardiography is the best evaluation tool to evaluate LV diastolic function. The purpose of this article is to provide the simplest stepwise approach of different diastolic parameters which are used as routine protocol with minimal use of the newer modalities at various clinical settings.
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Indian academy of echocardiography guidelines and manual for performance of stress echocardiography in coronary artery disease
Nitin Burkule, Manish Bansal
May-August 2017, 1(2):71-102
Stress echocardiography is one of the most useful non-invasive diagnostic modalities for detection and evaluation of coronary artery disease (CAD). It is also very useful for assessment of cardiac response to hemodynamic stress in a variety of other cardiac and non-cardiac disorders. Given its cost-effectiveness, stress echocardiography is particularly suited for Indian scenario where the incidence of CAD is rising at an alarming rate and the astronomical expenditure required for its management is borne largely by the patients themselves. However, despite its unequivocal diagnostic value, stress echocardiography remains underutilized, particularly in India, due to the lack of adequate exposure and training in this modality. Unfortunately, while there is extensive literature available to document diagnostic accuracy of stress echocardiography, there are very few texts that actually describe how to perform stress echocardiography in real life. This Indian Academy of Echocardiography guideline document aims to fill this very void. This is a comprehensive 'how to do' document prepared with the objective of providing detailed description of the steps involved in performance and interpretation of stress echocardiography so that there is increased adoption of this important and clinically useful diagnostic modality in daily clinical practice. However, while stress echocardiography has several clinical applications, the present document is restricted to its main application, which is evaluation of CAD.
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Non-ischemic regional wall motion abnormality
ST Yavagal, Vivek Bantwal Baliga
January-April 2019, 3(1):7-11
Regional wall motion abnormalities (RWMA) are usually described with Ischemic Heart Disease. But many other conditions also show RWMA. What are those conditions, how to recognize RWMA in them and what is it's importance is discussed.
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Carotid ultrasound for cardiovascular risk prediction: From intima-media thickness to carotid plaques
Ravi R Kasliwal, Mansi Kaushik, Hardeep Kaur Grewal, Manish Bansal
January-April 2017, 1(1):39-46
Carotid intima-media thickness (CIMT) and nonstenotic carotid plaques are established measures of subclinical atherosclerosis and are useful for prediction of future cardiovascular disease (CVD) risk. Compared with CIMT, the incremental predictive value of carotid plaques is more robust. Although the guidelines differ, carotid ultrasound-based assessment of CIMT and carotid plaques has a role in risk stratification and management of asymptomatic individuals who present with one or more CVD risk factors. The presence of significantly elevated CIMT or carotid plaque burden should lead to reclassification of the individuals into high-risk category with the appropriate intensification of the risk reduction measures. In addition, demonstration of increased CIMT and/or presence of the plaques may also help in improving patients' health behavior and their compliance toward antiatherosclerotic measures. In future, plaque progression/regression assessment by three-dimensional ultrasound and the use of contrast agents may further enhance the utility of carotid ultrasound for monitoring the clinical course of atherosclerotic vascular disease.
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The Indian Academy of Echocardiography practice guideline for the performance of transesophageal echocardiographic evaluation of a patient with cerebrovascular stroke
Nitin Burkule, Satish C Govind, Srikanth Sola, Manish Bansal
January-April 2018, 2(1):1-18
Ischemic stroke remains a major cause of morbidity and mortality. Cardiac sources of embolism account for almost up to 40% of all the ischemic strokes. Accordingly, echocardiography is an important investigation in the evaluation of clinically suspected cardioembolic stroke or cryptogenic stroke. Both transthoracic echocardiography and transesophageal echocardiography (TEE) are complementary to each other for this purpose. However, because of its superior resolution and the ability to image structures that are the most likely sources of cardioembolism (e.g., left atrial appendage), TEE is the preferred imaging modality in the cardiac evaluation of stroke. This document describes the systematic TEE evaluation of the patients referred with a clinical diagnosis of either cryptogenic stroke or cardioembolic stroke.
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Demystifying three-dimensional echocardiography: Keeping it simple for the sonographer
Eric John Kruse, Roberto M Lang
September-December 2017, 1(3):206-213
Three-dimensional echocardiography (3DE) is a new echocardiographic tool that enables echocardiographers visualization of cardiac structures from any anatomical view. Furthermore, the recent development of new transducer technology and software allows the easy acquisition and analysis of datasets for sonographers. A few common applications of 3DE consist of the left and right ventricle for chamber quantification, mitral valve stenosis and regurgitation assessment, and the guidance of catheter placement during interventional procedures. Despite current literature illustrating the importance of 3DE, it fails to demonstrate how to acquire 3D datasets from the sonographer's perspective. Understanding 3DE data acquisition technique and applications are paramount to implement it as standard of care. Acquisition of 3DE should be accomplished in three steps (1) optimization, (2) acquisition, and (3) cropping of 3D images.
  3,043 610 -
Multimodality imaging in restrictive cardiomyopathies: an European association of cardiovascular imaging expert consensus document in collaboration with the “Working group on myocardial and pericardial diseases” of the European Society of Cardiology endorsed by the Indian Academy of Echocardiography
Gilbert Habib, Chiara Bucciarelli-Ducci, Alida L.P. Caforio, Nuno Cardim, Philippe Charron, Bernard Cosyns, Aurélie Dehaene, Genevieve Derumeaux, Erwan Donal, Marc R Dweck, Thor Edvardsen, Paola Anna Erba, Laura Ernande, Oliver Gaemperli, Maurizio Galderisi, Julia Grapsa, Alexis Jacquier, Karin Klingel, Patrizio Lancellotti, Danilo Neglia, Alessia Pepe, Pasquale Perrone-Filardi, Steffen E Petersen, Sven Plein, Bogdan A Popescu, Patricia Reant, L Elif Sade, Erwan Salaun, Riemer H.J.A. Slart, Christophe Tribouilloy, Jose Zamorano
January-April 2018, 2(1):19-44
Restrictive cardiomyopathies (RCMs) are a diverse group of myocardial diseases with a wide range of aetiologies, including familial, genetic and acquired diseases and ranging from very rare to relatively frequent cardiac disorders. In all these diseases, imaging techniques play a central role. Advanced imaging techniques provide important novel data on the diagnostic and prognostic assessment of RCMs. This EACVI consensus document provides comprehensive information for the appropriateness of all non-invasive imaging techniques for the diagnosis, prognostic evaluation, and management of patients with RCM.
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Basics of tissue doppler revisited
Sita Ram Mittal
May-August 2017, 1(2):126-132
Tissue Doppler imaging (TDI) records velocities of myocardial tissue. Routinely longitudinal velocities of medial and lateral mitral annulus and lateral tricuspid annulus are evaluated in apical four chamber view. Commonly recorded waves include isovolumic contraction wave, systolic wave, isovolumic relaxation wave, early diastolic wave, and late diastolic wave. TDI is useful in detection of subclinical systolic dysfunction and early diastolic dysfunction. It is useful in differentiating athlete's heart from hypertrophic cardiomyopathy and pericardial constriction from restrictive cardiomyopathy.
  2,978 562 -
Early detection of a potentially fatal complication of coronary stent implantation using transthoracic two-dimensional-echocardiography
Jaywant M Nawale, Kshitij R Bedmutha, Rajendra Vishwambhar Chavan, Ajay S Chaurasia
May-August 2018, 2(2):115-117
The number of coronary stent (CS) implantation has significantly increased since its introduction in 1987. CS infection is a rare but potentially fatal complication. No imaging modality is confirmatory for diagnosing CS infection. Positive blood cultures, two-dimensional-echocardiography (especially transesophageal echocardiography), transthoracic echocardiography (TTE), coronary angiography, computed tomography-scan, and magnetic resonance imaging are useful. We report a case of a 65-year-old male who presented within a month of CS implantation with high-grade fever and chest pain. TTE showed a localized collection in the right atrioventricular groove clinching the diagnosis to CS infection. The patient responded to higher doses of broad-spectrum antibiotics which were continued for 6 weeks.
  3,363 153 -
Assessment of myocardial viability by echocardiography
Nitin J Burkule
January-April 2017, 1(1):32-38
Clinical application of myocardial viability testing to improve patient outcome is still a concept in evaluation. The various echocardiographic, nuclear, and magnetic resonance imaging techniques of assessment of myocardial viability evaluate different aspects of ischemic pathophysiology and have certain distinct advantages and limitations. A clinical algorithm combining “anatomic” and “flow/function” imaging gives more specific result of myocardial viability. Different modalities of echocardiography form the basic and cost-effective tools to assess the anatomic and functional aspect of viability.
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Evaluation of coronary arteries by transthoracic echocardiography
AV Anjaneyulu
January-April 2017, 1(1):27-31
Though several new cardiac imaging techniques have emerged, invasive coronary angiography remains the gold standard in evaluating coronary arteries for measuring anatomic severity of the stenotic lesion and assisting in intracoronary interventions. Several workers have attempted to image the coronary arteries by echocardiography. With improvements in ultrasound machines and introduction of harmonic imaging and high frequency transducers, direct visualization of long segments of all three coronary arteries is now possible. Though the entire artery cannot be reconstructed, multiple segments can be visualized, flow velocity can be measured, thus enabling us to obtain useful anatomic and physiologic information. Careful evaluation of coronary flows can translate into a wide variety of clinical applications.
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Speckle-Tracking echocardiography to assess global and regional left ventricular function in acute myocardial infarction
Gopi Aniyathodiyil, Sunil S Bohra, Anup Mottengar, Satish C Govind
September-December 2017, 1(3):177-184
Speckle tracking is a useful tool in assessing global & regional myocardial function in patients with acute myocardial infarction undergoing primary PCI. Global Longitudinal Strain (GLS) is a robust parameter to assess regional and global LV function. Global longitudinal strain helps in predicting short term outcomes in these patients and has shown to be better than ejection fraction, and as good as wall motion scoring, wall motion scoring index and myocardial performance index. A Lower global longitudinal strain parallels the rise in troponin T and CPKMB in acute myocardial infarction. Global longitudinal strain may have the potential to be an echocardiographic parameter which is useful in identifying multivessel disease. Assessment of regional myocardial function by speckle tracking echocardiography, particularly GLS, can be useful in ACS patients undergoing PCI in predicting short term recovery of the affected segments. Speckle tracking echocardiography can be used independent of the conventional markers to assess regional and global LV function.
  2,203 391 -
Role of stress echocardiography in mitral valve disease
Manish Bansal, Hardeep Kaur Grewal, Ravi R Kasliwal
May-August 2017, 1(2):140-148
Echocardiography is pivotal in the evaluation and management of valvular heart disease. Conventionally, echocardiographic assessment of any valve disease is performed at rest. However, as valvular heart disease is a dynamic entity, evaluation only at rest is not sufficient to assess the true hemodynamic severity of the valve lesion. For this reason, stress echocardiography (SE) serves as a useful diagnostic modality. By permitting evaluation under hemodynamic stress, it provides incremental diagnostic and prognostic information which has significant therapeutic implications. Further, exercise SE also permits correlation of the symptoms with the severity of the underlying valve disease. This information is crucial as the development of symptoms is a Class I indication for intervention in valve disorders. These benefits coupled with the easy availability and safety of SE should lead to its more routine application in the management of the patients with valvular heart disease. The present review describes the technical aspects and the clinical utility of SE in the evaluation and management of mitral valve disease.
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Reversible cardiomyopathies
Anjaneyulu V Anne
May-August 2018, 2(2):106-111
Cardiac muscle dysfunction resulting in heart failure can be reversed with appropriate diagnosis and therapy in nearly 25%8211;50% of all nonischemic cardiomyopathies. Diverse etiologies such as congenital, metabolic, toxic, infective, inflammatory, infiltrative, stress induced, and arrhythmia induced can cause myocardial dysfunction which can be restored to normal. All morphologic types including dilated, hypertrophic, and restrictive cardiomyopathies can have an underlying reversible cause. Imaging modalities such as echocardiography, cardiac computed tomography (CT), positron-emission tomography-CT, and cardiac magnetic resonance along with appropriate biochemical tests can help diagnose these varied etiologies. Recognizing reversible myocardial dysfunction at an early stage of the disease helps avoid inappropriate prolonged therapy for heart failure and repeated hospital admissions and may result in a cure in a significant number of cases.
  2,202 374 -
Estimation of Z-scores of cardiac structures in healthy Indian pediatric population
Bhadra Trivedi, Manish Chokhandre, Poornima Dhobe, Swati Garekar
September-December 2018, 2(3):147-154
Introduction: Nomograms of pediatric cardiac structures are an effective tool to differentiate between normal and abnormal changes in dimensions of the heart. There is impending need for nomograms of Z-Scores of echocardiographic data derived from Indian children. Objective: The main objective of this study is to gather echocardiographic data from the healthy Indian pediatric population visiting the pediatric cardiology outpatient clinic and to derive the Z-Scores for various cardiac structures. Materials and Methods: All the echocardiographic studies from an eligible normal Indian population at a single centre were assessed. All the studies were performed on a single vendor echocardiography machine using weight appropriate neonatal, pediatric, and adult probes. Statistical Analysis: Body surface area (BSA) was used as an independent variable in a nonlinear regression analysis for the predicted mean value of each of the 19 echocardiographically measured structures. Results: The total number of children evaluated during the study period was 596, with age ranging from newborn to 16 years. The total parameters collected in the study were 8102. The correlation with Haycock's BSA and an individual parameter was found to be the most sensitive predictor of normal progression with age. Relationship of individual parameters with BSA was represented in the form of graphs. Conclusion: This study of normal Indian pediatric population is the largest Indian study to date. The regression formulae along with the graphs can be used to acquire the Z score of 19 individual echocardiographic parameters.
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Functional assessment of fetal heart: Normative data for tissue doppler indices and other echocardiographic parameters for Indian population
Anupama Nair, Sitaraman Radhakrishnan
May-August 2017, 1(2):103-108
Objective: To establish normative data for tissue Doppler indices and other parameters for ventricular function assessment in fetal imaging for the Indian population and to assess the variation of these parameters with gestational age. Materials and Methods: A prospective study involving 172 fetuses diagnosed as having normal cardiac structure and function. Mothers were advised for fetal echocardiography for several indications; however, mothers with diabetes (both gestational and pregestational), placental dysfunction, fetuses with intrauterine growth retardation, and multiple gestation were excluded as these could affect the fetal cardiac function despite a normal cardiac structure. Peak myocardial velocity was measured during systole (S'), early diastole (E'), and late diastole (A') using spectral tissue Doppler. Pulsed Doppler was used to measure the inflow early (E) and late (A) diastolic velocities and the diastolic filling period (DFP). M-mode was used to measure the tricuspid and mitral annular peak systolic excursion (TAPSE and MAPSE). Results: Normative data for tissue Doppler velocities and various other parameters for functional assessment of fetal heart were derived from the 172 normal fetuses. On tissue Doppler imaging (TDI), the mean values for the peak systolic and diastolic velocities at the lateral and medial mitral annulus and at the lateral tricuspid annulus and ratio of early and late diastolic velocity (E'/A') increased while the (E/E') ratio decreased with gestational age. Other parameters that increased with age are TAPSE, MAPSE, and the DFP at the tricuspid and mitral valves. The left and right ventricular myocardial performance index did not show any variation with gestation. Conclusion: TDI has already been documented as a useful technique in fetal cardiac imaging. The normative data so derived for various parameters can be used as a future reference. These parameters can prove very useful in fetal cardiac functional evaluation and detection of systolic or diastolic dysfunction at an early stage which may have long-term and prognostic implications.
  2,059 290 -
Three-dimensional versus two-dimensional strain for the assessment of myocardial function: A case series
Monica Vinesh Dillikar, Ashwin Venkateshvaran, Banajit Barooah, Reeta Varyani, Prayaag Kini, PK Dash, Srikanth Sola
January-April 2017, 1(1):18-23
Introduction: Two-dimensional (2D) strain assessment is an important diagnostic and prognostic tool in various clinical conditions, particularly coronary artery disease (CAD). However, these measurements are limited in that the information is obtained in only a single plane (2D). Three-dimensional (3D) strain tracks the myocardium in all 3D, potentially overcoming the limitation of 2D strain. The objective of this study was to establish normal values for 3D strain in a population of healthy, normal controls and to compare these values with 2D strain values. In addition, we sought to evaluate the utility of 3D strain in patients with known or suspected CAD. Methods: We conducted a prospective study at a single major tertiary care center. Individuals were recruited for the study and divided into two groups: a normal control group and a CAD group. Global longitudinal strain (GLS) and global circumferential and global radial strain were calculated by both 2D and 3D strain methods. In addition, 3D was used to calculate area strain. Results: We enrolled a total of 43 individuals (20 normal control group, mean age 33 ± 2.7 years, and 23 CAD group, mean age 57 ± 2.8 years, 80% male). Values for 3D strain were consistently lower for GLS and global circumferential strain in both groups compared with 2D measurements. In the control group, the mean 2D GLS was −20 ± 1.6% versus −17.5 ± 1.5% for 3D GLS (P < 0.001). Similarly, the mean 2D circumferential strain was −17.7 ± 2.3% versus −15.6 ± 2.1% for 3D circumferential strain (P < 0.001). Combining both groups, the sensitivity of GLS for CAD was 80% for 2D versus 93% for 3D. Similar findings were seen for global circumferential strain (sensitivity 87% for 2D vs. 100% for 3D). However, the sensitivity of 3D global radial strain was lower (93% for 2D vs. 47% for 3D). 3D strain data were acquired in a shorter time span compared with 2D (2.2 ± 1 min vs. 3 ± 1 min). Conclusions: 3D strain assessment of longitudinal and circumferential strain is similar but mildly reduced compared with 2D techniques, with similar sensitivity for CAD. Radial strain measurements by 3D, however, are not accurate and correlate poorly with 2D.
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A journey from adult to fetal echocardiography
UP Singh, Hargunbir Singh, Ladbans Kaur
September-December 2018, 2(3):155-160
As a cardiologist in a group practice or hospital settings, many a times you are requested to comment on fetal Echocardiography performed by radiologist or fetal medicine specialist. With overconfidence, we perform or comment on fetal echocardiography without knowing critical differences between adult and fetal echocardiography. First, fetal heart at 20 weeks of gestation is of the size of an almond. Due to the limitation of resolution of ultrasound machines, small size of fetal heart makes it difficult to visualize many direct signs of congenital heart defects such as total anomalous pulmonary venous connection (TAPVC), transposition of the great arteries (TGA), coarctation, and double outlet right ventricle (RV). Hence, in fetal echo, we use indirect signs and clues to diagnose these disorders. Second, there are two physiological shunts in fetal circulation; fossa ovalis and ductus arteriosus which make its very different from adult circulation. A cardiologist needs to know about indirect signs, special views, peculiar fetal cardiac defects, and hemodynamics of fetal circulation before attempting fetal echocardiography. Many of us have an impression that fetal heart is just a miniature form of adult heart. Fetal echocardiography is a lot different from adult or pediatric echocardiography because there are many structural and functional differences in fetal circulation. Moreover, many congenital heart defects such as TGA, TAPVC, and ventricular septal defect, can present with only subtle findings, so we need to be more vigilant while performing fetal echocardiography.
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