Journal of the American Society of Echocardiography

The Role of Echocardiography in the Management of Patients Supported by Extracorporeal Membrane Oxygenation

2011-12-12

Extracorporeal life support can be viewed as a spectrum of modalities based on modifications of a cardiopulmonary bypass circuit to provide cardiac and respiratory support, which can be used for extended periods, from hours to several weeks. Extracorporeal membrane oxygenation (ECMO) is among the most frequently used forms of extracorporeal life support. It can be configured for venovenous blood flow, to provide adequate oxygenation and carbon dioxide removal in isolated refractory respiratory failure, or in a venoarterial configuration, when support is required for cardiac and/or respiratory failure. Echocardiography plays a fundamental role throughout the entire journey of a patient supported on ECMO. It provides information that assists in patient selection, guides the insertion and placement of cannulas, monitors progress, detects complications, and helps in determining cardiac recovery and the weaning of ECMO support. Although there are extensive published data regarding ECMO, particularly in the pediatric population, there is a paucity of data outlining the role of echocardiography in guiding the management of adult patients supported by ECMO. ECMO is likely to become an increasingly used form of cardiorespiratory support within the critical care setting. Hence, clinicians and sonographers who work within echocardiography departments at institutions with ECMO programs require specific skills to image these patients.

Limitations of Current Echocardiographic Nomograms for Left Ventricular, Valvular, and Arterial Dimensions in Children: A Critical Review

2011-11-21

An echocardiographic quantitative evaluation of the cardiac and vascular structures is often of critical importance for the diagnosis and management of congenital heart diseases. The authors reviewed the accuracy and limits of published echocardiographic nomograms for cardiac chamber, valve, and main vessel dimensions in children, with special attention to the neonatal age group. A computerized literature search in the National Library of Medicine using the keywords “echocardiographic normal/references values ± children/neonates/newborns” was performed. The research was redefined adding separately the keywords “aortic valve/annulus,” “aortic arch,” “atrio-ventricular valve/annulus,” “left ventricle,” “mitral valve/annulus,” “pulmonary valve/annulus,” “pulmonary artery,” and “tricuspid valve/annulus.” The analysis highlights the accuracy of the latest studies but also underscores that some limitations remain. In many studies, the number of healthy subjects was limited, with poor differentiation among age subgroups, and neonates were fully investigated in a very limited number of studies; moreover, data for many cardiac structures were not numerous, especially for the aortic arch and pulmonary branches. Finally, several methodologic limitations were encountered, including the lack of standardization, the different types of body size measurements used for normalization, and the various ways to express normalized data. As a result, nomograms were heterogeneous and although for some cardiac structures provided comparable confidence intervals, for others showed widely different values. The lack of solid, standardized nomograms, based on a large set of healthy children, may affect accuracy in estimating the severity of defects, especially in neonates, and possibly introduce bias in the clinical decision-making process.

Alteration in Subendocardial and Subepicardial Myocardial Strain in Patients with Aortic Valve Stenosis: An Early Marker of Left Ventricular Dysfunction?

2011-12-01

Background: It has been suggested that myocardial systolic impairment may not be accurately detected by the evaluation of endocardial excursion alone. The aim of this study was to test the hypothesis that changes in left ventricular (LV) subendocardial and subepicardial strain are sensitive markers of severity of aortic stenosis (AS) and LV function in patients with AS.Methods: Transthoracic echocardiography was performed in 73 consecutive patients with AS who had preserved systolic function and in 20 controls. Longitudinal strain, subendocardial radial strain, subepicardial radial strain, and transmural radial strain were measured using LV apical and short-axis images.Results: The 73 patients enrolled in this study were classified according to AS severity: mild (n = 10), moderate (n = 15), or severe (n = 48). Although transmural and subepicardial radial strain showed similar values in all groups, subendocardial radial strain and longitudinal strain could differentiate mild or moderate AS from severe AS. Only the ratio of subendocardial to subepicardial radial strain (the bilayer ratio) decreased significantly as the severity of AS increased. Bilayer ratio showed weak correlations with LV ejection fraction (r = 0.37) and E/E′ ratio (r = −0.33) and moderate correlations with LV mass (r = −0.55) and aortic valve area (r = 0.71). Moreover, bilayer ratio was independently associated with AS severity (P = .001). In 21 patients who underwent aortic valve replacement, subendocardial radial strain and bilayer ratio increased 7 days after surgery, whereas other echocardiographic parameters of LV function showed no improvement.Conclusions: Bilayer ratio can reliably differentiate patients with varying degrees of AS severity and is a sensitive marker of LV function. These findings suggest that the evaluation of subendocardial and subepicardial radial strain might be a novel method for assessing LV mechanics in patients with AS.

Mitral Regurgitation in Patients Referred for Transcatheter Aortic Valve Implantation Using the Edwards Sapien Prosthesis: Mechanisms and Early Postprocedural Changes

2011-11-10

Background: Transcatheter aortic valve implantation (TAVI) is an alternative to conventional surgery in high-risk patients with severe aortic stenosis (AS), but data regarding mitral regurgitation (MR) characteristics and changes after TAVI are sparse.Methods: A total of 254 patients with severe AS referred for TAVI were prospectively enrolled. Comprehensive echocardiography was performed at baseline and at 7 days and 1 month in patients who underwent TAVI. MR was semiquantitatively graded from 0 to 4. Overlap of the anterior mitral leaflet and the device was measured using transesophageal echocardiography immediately after TAVI.Results: At screening, MR was absent in 26%, grade 1 in 44%, grade 2 in 25%, and grade ≥3 in 5% and was organic in 68% and functional in 32%. TAVI was finally performed using the Edwards Sapien valve in 119 patients, including four with MR grade ≥ 3. MR grade significantly decreased at 7 days (P = .003) but remained unchanged at 1 month (P = .55), whereas reverse remodeling occurred only at 1 month (improvements in left ventricular [LV] end-systolic diameter and ejection fraction; P < .05 for both). MR changes over time significantly differed according to ejection fraction and LV diameters (all P values for interaction .15).Conclusions: In patients referred for TAVI, MR is common, mainly organic, and rarely severe. After TAVI, MR improved within 7 days in both organic and functional MR, was not influenced by overlap of the anterior mitral leaflet and the device, but was associated with improvement in LV ejection fraction. Possible MR improvement should be taken into account in patient selection for TAVI especially, in cases of LV dysfunction or enlargement and MR of borderline severity.

Left Ventricular Outflow Tract: Intraoperative Measurement and Changes Caused by Mitral Valve Surgery

2011-11-14

Background: The impact of mitral valve surgery on left ventricular outflow tract (LVOT) dimensions is unclear. Real-time three-dimensional transesophageal echocardiography permits excellent visualization of the LVOT and might improve standard two-dimensional measurements. In this study, LVOT area and shape were assessed before and after mitral valve surgery.Methods: Thirty-five patients undergoing mitral valve repair or replacement were retrospectively included in the study and compared with 15 patients undergoing coronary artery bypass grafting. LVOT area was measured by planimetry. Maximum possible methodologic errors by assuming a circular LVOT and an eccentricity index were calculated. LVOT diameter in a midesophageal long-axis view served to calculate the error for the circular LVOT determined in common intraoperative practice.Results: Common intraoperative two-dimensional measurements underestimated actual LVOT area by 21%. Mitral valve surgery led to a significant reduction of LVOT area by 7%. Although LVOT height remained unchanged, width decreased from 2.72 to 2.53 cm (−7%), resulting in a more circular shape of the LVOT. This effect was more pronounced the smaller the size of the implanted annuloplasty ring or prosthesis. Coronary artery bypass grafting did not affect the LVOT. Left ventricular ejection fraction was significantly correlated with LVOT eccentricity. Impaired ventricular function and higher end-systolic volumes were associated with a rounder shape.Conclusions: The eccentric LVOT shape leads to a distinct underestimation of its area with two-dimensional measurements. LVOT eccentricity is less distinct in patients with low ejection fractions and higher end-systolic volumes. LVOT width is decreased through annuloplasty rings and prostheses, and the smaller the implanted device, the more profound the reduction.

Comprehensive Hemodynamic Assessment of 305 Normal CarboMedics Mitral Valve Prostheses Based on Early Postimplantation Echocardiographic Studies

2011-12-02

Background: Two-dimensional (2D) and Doppler-derived echocardiographic data on normal CarboMedics (CM) mechanical mitral valve prosthesis function have been reported but are limited.Methods: Comprehensive retrospective 2D and Doppler echocardiographic assessment of 305 normal CM mechanical mitral valve prostheses (272 Standard and 33 Optiform) was performed early after implantation. The early postimplantation hemodynamic profiles of 80 patients were compared with profiles obtained by follow-up transthoracic echocardiography performed <1 year after implantation.Results: CM Standard and Optiform prostheses had similar hemodynamic profiles. With mean ± 2 SDs used to define the normal distribution of values for hemodynamic variables, the calculated normal range of values was as follows: mean gradient, 2 to 7 mm Hg; peak early mitral diastolic velocity, 1.3 to 2.4 m/sec; time-velocity integral (TVI) of the mitral valve prosthesis (TVIMVP), 20 to 50 cm; ratio of TVIMVP to the TVI of the left ventricular outflow tract, 0.9 to 2.5; pressure half-time, 35 to 99 msec; and effective orifice area, 1.17 to 3.25 cm2. Patients with severe prosthesis-patient mismatch (indexed effective orifice area ≤ 0.9 cm2/m2) had significantly higher mean gradients, peak early mitral diastolic velocities, TVIMVP, ratios of TVIMVP to the TVI of the left ventricular outflow tract, and pressure half-time values than values without severe prosthesis-patient mismatch, but none had pressure half-time values > 120 msec. Among the 80 patients with follow-up transthoracic echocardiography within 1 year after implantation, no significant differences were noted between early postimplantation findings and follow-up hemodynamic profiles.Conclusions: This study establishes parameters (mean ± 2 SD) defining the distribution of findings for Doppler-derived hemodynamic data with normal CM mechanical mitral valve prostheses. Prostheses with hemodynamic values outside these parameters are likely dysfunctional; however, prosthesis dysfunction may be present even when hemodynamic values are within these ranges.

Prognostic Value of Exercise Echocardiography in Patients with Hypertrophic Cardiomyopathy

2011-12-05

Background: Although exercise echocardiography may assess left ventricular (LV) function and LV outflow tract (LVOT) gradients during exercise in patients with hypertrophic cardiomyopathy (HCM), its value for predicting outcomes has not been studied. The aim of this study was to determine whether exercise echocardiography predicts outcomes in patients with HCM.Methods: LV function and LVOT gradients were evaluated during exercise echocardiography in 239 patients with HCM.Results: Sixty patients (25.1%) had LVOT obstruction at rest, and 43 (18%) developed exercise-induced LVOT obstruction. The mean resting LV ejection fraction was 69 ± 9%, and the mean resting wall motion score index was 1.00 ± 0.06. Wall motion abnormalities during exercise were seen in 19 patients (7.9%). During follow-up of 4.1 ± 2.6 years, 19 patients had hard events (cardiac death, cardiac transplantation, appropriate discharge of a defibrillator, stroke, myocardial infarction, or hospitalization for heart failure), and 41 patients had composite end points of hard or soft events (including atrial fibrillation and syncope). Exercise wall motion abnormalities occurred in 31.5% of patients with hard events compared with 5.9% of patients without hard events (P < .001). After adjustment, LV wall thickness (hazard ratio [HR], 1.13; 95% confidence interval [CI], 1.05–1.21; P = .002), resting wall motion score index (HR, 21.59; 95% CI, 2.38–196.1, P = .006), and metabolic equivalents (HR, 0.74; 95% CI, 0.63–0.88; P = .001) remained independent predictors of hard events. Change in wall motion score index was also independently associated with hard events (HR, 52.30; 95% CI, 3.81–718.5; P = .003) and with the composite end point (HR, 39.51; 95% CI, 3.79–412.4; P = .002). LVOT obstruction was not associated with either end point.Conclusions: Assessment of exercise capacity and LV systolic function during exercise echocardiography may have a role in risk stratification of patients with HCM.

Predicting the Future in Hypertrophic Cardiomyopathy: From Histopathology To Flow To Function

Lynne Williams, Harry Rakowski — 2012-02-01

Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disease with both variable penetrance and a wide spectrum of phenotypic expression. Although there are several established risk factors for sudden cardiac death and progression to heart failure, these markers individually have low positive predictive value and only modestly high negative predictive value. Although the exact mechanisms are incompletely understood as yet, underlying abnormalities of myocardial architecture are thought to play a role in arrhythmogenesis and left ventricular (LV) remodeling. Alterations in myocardial structure at both macroscopic and microscopic levels predispose to myocardial ischemia, which may be associated with such complications as LV remodeling and progression to systolic dysfunction and heart failure. Myocardial imaging both at rest and during stress provides the opportunity to study alterations in myocardial function resulting from ischemia and abnormal loading conditions and to identify markers of adverse prognosis in these patients.

Reproducibility of Echocardiographic Diagnosis of Left Ventricular Noncompaction

2011-10-31

Background: Left ventricular noncompaction (LVNC) cardiomyopathy is variably defined by numerous trabeculations, deep intertrabecular recesses, and noncompacted-to-compacted (NC/C) ratio >2. Limited studies exist on the reproducibility of diagnosing LVNC.Methods: Clinical records of patients diagnosed with LVNC by echocardiography were reviewed. Blinded review of the index echocardiogram for all patients and a 1:1 match without LVNC was performed independently by two observers, measuring the number of trabeculations and the NC/C ratio.Results: A total of 104 patients with LVNC were included in the study, 52 with no congenital heart disease (NCongHD) and 52 with congenital heart disease (CongHD). The duration of follow-up was 7.2 years (range, 0.5–23.1 years) for NCongHD and 8.2 years (range, 0–33.3 years) for CongHD. Agreement between observers in determining zero to three versus more than three trabeculations was 59% (NCongHD) and 73% (CongHD). Agreement in measuring an NC/C ratio ≤ 2 versus > 2 was 79% (NCongHD) and 74% (CongHD). Agreement with the original reader in diagnosing LVNC was 67%. There was no association between the number of trabeculations or the NC/C ratio and the likelihood of a major event. Patients with moderate or severe left ventricular dysfunction at the time of diagnosis were more likely to undergo cardiac transplantation or die compared with those with normal or mild dysfunction (NCongHD, 22% vs 0%, P = .01; CongHD, 39% vs 3%, P = .001).Conclusions: The reproducibility of making measurements to diagnose LVNC by accepted criteria is poor. Heart transplantation and death are associated with significant ventricular dysfunction and not with increased trabeculations or NC/C ratios.

Three-Dimensional Echocardiographic Characterization of Patients with Left Ventricular Noncompaction

2011-12-12

Background: Despite several efforts using two-dimensional echocardiography and cardiac magnetic resonance in the diagnosis of left ventricular noncompaction (LVNC), there are no universally accepted diagnostic criteria. The aim of this study was to describe the extent of noncompacted myocardium using a new three-dimensional echocardiographic parameter.Methods: Seventeen patients with diagnoses of LVNC on the basis of two-dimensional echocardiographic and clinical criteria, 26 Olympic rowing athletes, and 49 healthy volunteers underwent three-dimensional echocardiography. By offline analysis, left ventricular volumes, mass, ejection fraction, and sphericity index were calculated. Trabeculated left ventricular volume (TLV) was calculated as the difference between left ventricular end-diastolic volume obtained including and excluding the trabeculae in the cavity contour. TLV was also normalized by left ventricular end-diastolic volume (TLV%).Results: TLV and TLV% were significantly higher in patients with LVNC (33.7 ± 10.9 mL and 24 ± 7%) as opposed to controls (7.1 ± 2.2 mL, P < .001, and 6 ± 2%, P < .001, respectively) and athletes (8.0 ± 3.0 mL, P < .001, and 5 ± 2%, P < .001, respectively). In detail, on receiver operating characteristic curve analysis, optimal cutoff values of 15.8 mL for TLV and 12.8% for TLV% were determined for the identification of LVNC (area under the curve, 1.00; P < .001). Mild positive correlations of TLV and TLV% were found with sphericity index (r = 0.294, P = .004, and r = 0.301, P = .004, respectively), and mild negative correlations were found with ejection fraction (r = −0.454, P < .001, and r = −0.217, P = .038, respectively).Conclusions: Because of high spatial resolution and accuracy in volumetric quantification, three-dimensional echocardiography allows accurate measurement of the extent of noncompacted myocardium and identification of patients with LVNC.

Impact of a Dedicated Training Program on the Reproducibility of Systolic Dyssynchrony Measures Using Tissue Doppler Imaging

2011-12-09

Background: The reproducibility of the measurement of mechanical dyssynchrony by echocardiography including Doppler tissue imaging has recently been questioned. The aim of this study was to ascertain the role of a dedicated training program to improve skills and the reproducibility of dyssynchrony assessment.Methods: In 70 patients with heart failure, color Doppler tissue images were acquired, and the time to peak systolic velocity of each segment and several dyssynchrony indices, including the standard deviation of time to peak systolic velocity, were measured by an expert to constitute a reference standard. The same images were then assessed by two beginners, who had only basic knowledge of dyssynchrony analysis after a 1-hour lecture, and two graduates, who had received a structured hands-on training program. Both sets of results were compared with the standard.Results: For the standard deviation of time to peak systolic velocity, the linear correlations between the standard and beginner 1 (r = 0.643) and beginner 2 (r = 0.532) were only modest (P < .001 for both). When referenced to the standard, interobserver variability was 18% for beginner 1 and 19% for beginner 2. Measurements with differences of ≥10 msec were found in 24% and 22% of cases by beginners 1 and 2, respectively. In contrast, the assessments made by graduates 1 and 2 were significantly improved. The correlation coefficients were 0.935 and 0.929 (P < .001 for both), and interobserver variability values were 8% and 7%. The prevalence rates of measurements with differences ≥ 10 msec were 1.5% and 3%, respectively.Conclusions: There is a learning curve for the measurement of systolic dyssynchrony using Doppler tissue imaging, but good reproducibility can be achieved by the use of a dedicated training program.

The Importance of Being Expert: Is It Time to Revisit the Concept?

Abigail May Khan, Susan E. Wiegers — 2011-12-19

Experience matters in medicine. In the current era of lengthy training programs and sub-subspecialization, this statement is hard to dispute. The concept that experience matters is not limited to medicine, having also permeated popular culture. Malcolm Gladwell's book Outliers, published in 2008, stresses the importance of repetition in achieving excellence, citing a pioneering study by Ericsson et al. demonstrating the relationship between hours of practice and skill level among musicians.

Assessment of Transmitral Vortex Formation in Patients with Diastolic Dysfunction

Arash Kheradvar, Ramin Assadi, Ahmad Falahatpisheh, Partho P. Sengupta — 2011-11-18

Background: Previous experimental models have related transmitral vortex formation to the longitudinal recoil of left ventricle. However, little is known about the relationships among left ventricular (LV) longitudinal relaxation, transmitral filling patterns, and LV vortex formation in clinical settings. The aim of this study was to compare the vortex formation time index among a heterogeneous group of patients with diastolic dysfunction to understand the relationship between transmitral vortex formation and abnormal diastolic filling patterns.Methods: Echocardiographic data from 107 subjects were retrospectively evaluated. The study population was categorized into four groups on the basis of transmitral early and late diastolic Doppler filling patterns as normal (n = 45), impaired relaxation (n = 14), pseudonormal (n = 26), and restrictive (n = 22). Vortex formation time was computed from the governing equations based on transmitral flow and ejection fraction.Results: Differences in vortex formation time index were found to be significant among all the studied groups (P < .0001). The trend of vortex formation during a cardiac cycle was compared in normal hearts and those with diastolic dysfunction. Mitral annular velocity (e′) was found to decrease significantly (P < .0001) in subjects with abnormal transmitral filling patterns compared with normal subjects. The difference in e′ among all the affected groups was not found to be significant (P = .68).Conclusions: The findings of this study suggest that patients with different patterns of transmitral diastolic filling show significant changes in LV vortex formation time despite the absence of significant differences in mitral annulus recoil during diastole.

Does the Revised Appropriate Use Criteria for Echocardiography Represent an Improvement Over the Initial Criteria? A Comparison between the 2011 and the 2007 Appropriateness Use Criteria for Echocardiography

Puja B. Parikh, John Asheld, Smadar Kort — 2011-10-19

Background: The appropriateness use criteria (AUC) for the performance of transthoracic echocardiography were recently revised. The aims of this study were to evaluate the 2011 AUC for echocardiography for their ability to categorize indications not addressed by the older AUC and to identify trends in ordering unclassified and inappropriate studies when applying the new AUC.Methods: We reviewed 384 consecutive adult transthoracic echocardiographic studies performed at a tertiary care teaching hospital. The appropriateness of each study was determined applying both the 2007 and the 2011 AUC.Results: Among the 384 studies evaluated, 212 (55.2%) were performed in men, 261 (67.9%) were inpatient studies, and 186 (48.4%) were ordered by cardiologists. Compared with the older 2007 AUC, applying the new 2011 AUC demonstrated a lower rate of unclassified studies (5.5% vs 12.5%), higher rates of appropriate (92.2% vs 86.7%) and inappropriate (1.8% vs 0.8%) studies, and no significant change in the rate of uncertain studies (0.5% vs 0.0%). Of the 5.5% of studies that continued to be unclassified despite the application of the more extensive 2011 AUC, common indications included preoperative evaluation for non-transplantation surgery in patients with coronary artery disease, postoperative assessment of thoracic aortic surgery in the absence of any clinical change, and reassessment of ventricular function after revascularization in the absence of acute coronary syndromes.Conclusions: Compared with the 2007 AUC for transthoracic echocardiography, application of the recently revised 2011 criteria leads to a significant decrease in the number of studies that are not classified, demonstrating that the AUC revision was successful in achieving the goal of addressing more clinical indications.

Epicardial Adipose Tissue Relating to Anthropometrics, Metabolic Derangements and Fatty Liver Disease Independently Contributes to Serum High-Sensitivity C-Reactive Protein Beyond Body Fat Composition: A Study Validated with Computed Tomography

2011-10-21

Background: Epicardial adipose tissue (EAT) measured by echocardiography has been proposed to be associated with metabolic syndrome and increased cardiovascular risks. However, its independent association with fatty liver disease and systemic inflammation beyond clinical variables and body fat remains less well known.Methods: The relationships between EAT and various factors of metabolic derangement were retrospectively examined in consecutive 359 asymptomatic subjects (mean age, 51.6 years; 31% women) who participated in a cardiovascular health survey. Echocardiography-derived regional EAT thickness from parasternal long-axis and short-axis views was quantified. A subset of data from 178 randomly chosen participants were validated using 16-slice multidetector computed tomography. Body fat composition was evaluated using bioelectrical impedance from foot-to-foot measurements.Results: Increased EAT was associated with increased waist circumference, body weight, and body mass index (all P values for trend = .005). Graded increases in serum fasting glucose, insulin resistance, and alanine transaminase levels were observed across higher EAT tertiles as well as a graded decrease of high-density lipoprotein (all P values for trend <.05). The areas under the receiver operating characteristic curves for identifying metabolic syndrome and fatty liver disease were 0.8 and 0.77, with odds ratio estimated at 3.65 and 2.63, respectively. In a multivariate model, EAT remained independently associated with higher high-sensitivity C-reactive protein and fatty liver disease.Conclusions: These data suggested that echocardiography-based epicardial fat measurement can be clinically feasible and was related to several metabolic abnormalities and independently associated fatty liver disease. In addition, EAT amount may contribute to systemic inflammation beyond traditional cardiovascular risks and body fat composition.

Neonatology Concerns about the TNE Consensus Statement

Nick Evans, Martin Kluckow — 2011-12-12

There is much within the targeted neonatal echocardiography (TNE) consensus statement we endorse, particularly the clinical indications, the need for training structures, and the importance of collaboration with other specialties involved in imaging, especially pediatric cardiology. However, we have concerns.

Neonatal Echocardiography—Different Approaches in Different Continents: Reply to a Letter by Evans and Kluckow

Luc Mertens, ASE Writing Group on Targeted Neonatal Echocardiography — 2011-12-19

We thank Drs. Evans and Kluckow for their interest in our recently published guidelines for neonatal echocardiography. We read their comments with interest, and we take note of the differences between their approach and the one outlined in the combined North American–European initiative. The aim of our writing group was to define minimum standards for neonatal echocardiography to guarantee high-quality diagnostic imaging performed by well-trained professionals. This was based on a collaborative model between cardiologists and neonatologists.

Right Ventricular Function Parameters in the Neonatal Population

Martin Koestenberger, William Ravekes — 2011-12-22

We read with interest the expert consensus statement “Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: Practice Guidelines and Recommendations for Training” from the writing group of the American Society of Echocardiography in collaboration with the European Association of Echocardiography and the Association for European Pediatric Cardiologists by Mertens et al. In our opinion, this is an excellent statement describing the current indications for targeted neonatal echocardiography (TNE), defining recommendations for the performance of TNE, and proposing training requirements for operators performing and interpreting TNE.

Assessment of Right Ventricular Function in Targeted Neonatal Echocardiography: Reply to Letter by Dr. Koestenberger and Dr. Ravekes

Luc Mertens, ASE Writing Group on Targeted Neonatal Echocardiography — 2012-02-01

We thank Drs. Koestenberger and Ravekes for their very valuable comments on our recently published guidelines on targeted neonatal echocardiography. As stated in the guidelines, we indeed recommended the use of quantitative measurements in the assessment of right ventricular function. At the time of the publication of the guidelines, no good reference values for tricuspid annular plane systolic excursion or systolic tissue Doppler velocities were available for neonates and preterm infants. The recent contributions by Dr. Koestenberger’s group fill this gap, as they have published excellent reference data based on a large group of normal term and preterm infants. The availability of Z scores for tricuspid annular plane systolic excursion and systolic tissue Doppler velocities provides us with the necessary tools and allows us to include these simple measurements in a standard targeted neonatal echocardiographic examination. We still need to understand how disease affects measurements in this population, but we consider this an important first step. We thank the authors for providing these valuable additions to our guidelines. We hope that further research done by different groups worldwide will provide us with better tools to assess neonatal hemodynamics.

2012-02-01

Editorial Board

2012-02-01

Information for Authors

2012-02-01

Information for Readers

2012-02-01

ASE 2012: Taking the Best of the Past and Making It Better!

2012-02-01

Registration has opened for the Society’s annual scientific sessions, and we have a fantastic line-up for the meeting. ASE 2012 will be held at National Harbor, MD (just outside Washington, DC) from June 30–July 3. Just as our meeting ends, the Fourth of July celebration begins, and where better to celebrate July 4th than in the nation’s capital, with fairs, parades, concerts and, of course, fireworks over the Potomac? For our overseas attendees, this is a wonderful opportunity to engage in a real American tradition. Come for the meeting; stay for the Fourth!

CPT, CMS, RUC, RBRVS: Why This Alphabet Soup—and Filling Out Surveys—Matters to You and Your Practice!

2012-02-01

ASE is an active participant in a process that is little understood, but essential to virtually every U.S. based member. It's known as the “RUC process,” a series of meetings of the Relative Value Scale Update Committee, or RUC.

Continuing Education and Meeting Calendar

2012-02-01

The American Society of Echocardiography is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ASE recognizes courses as supplements to formal training in an established echocardiographic laboratory. For more information about a course, please call the number listed. To list a course in the Continuing Education and Meeting Calendar, send the date(s), title, location, sponsor, course director(s), and contact information to ASE, Attn: Cheryl Williams, 2100 Gateway Centre Boulevard, Suite 310, Morrisville, NC 27560; Tel: 919-861-5574 x7160; E-mail: cwilliams@asecho.org.

A New Career Ladder for Sonographers

2012-02-01

In 2007, ASE sponsored a sonographer needs survey which indicated that 94% of respondents were interested in acquiring information about an educational program providing advanced cardiovascular sonography curriculum, and that 86% of respondents were interested in returning to school to become an advanced cardiovascular sonographer. Since this time, ASE has heard the call to action and supported the development of a new career ladder for sonographers.

Keeping Current in Vascular Imaging

2012-02-01

As the chair-elect of the Vascular Council Board, I am impressed by ASE's commitment to advancing vascular imaging. Staying current with recent advances in vascular care and imaging can be challenging. This communication highlights activities and resources, particularly within ASE, that will help keep you informed about state-of-the-art vascular imaging.

Journal of the American Society of Echocardiography

The Role of Echocardiography in the Management of Patients Supported by Extracorporeal Membrane Oxygenation

Limitations of Current Echocardiographic Nomograms for Left Ventricular, Valvular, and Arterial Dimensions in Children: A Critical Review

Alteration in Subendocardial and Subepicardial Myocardial Strain in Patients with Aortic Valve Stenosis: An Early Marker of Left Ventricular Dysfunction?

Mitral Regurgitation in Patients Referred for Transcatheter Aortic Valve Implantation Using the Edwards Sapien Prosthesis: Mechanisms and Early Postprocedural Changes

Left Ventricular Outflow Tract: Intraoperative Measurement and Changes Caused by Mitral Valve Surgery

Comprehensive Hemodynamic Assessment of 305 Normal CarboMedics Mitral Valve Prostheses Based on Early Postimplantation Echocardiographic Studies

Prognostic Value of Exercise Echocardiography in Patients with Hypertrophic Cardiomyopathy

Predicting the Future in Hypertrophic Cardiomyopathy: From Histopathology To Flow To Function

Reproducibility of Echocardiographic Diagnosis of Left Ventricular Noncompaction

Three-Dimensional Echocardiographic Characterization of Patients with Left Ventricular Noncompaction

Impact of a Dedicated Training Program on the Reproducibility of Systolic Dyssynchrony Measures Using Tissue Doppler Imaging

The Importance of Being Expert: Is It Time to Revisit the Concept?

Assessment of Transmitral Vortex Formation in Patients with Diastolic Dysfunction

Does the Revised Appropriate Use Criteria for Echocardiography Represent an Improvement Over the Initial Criteria? A Comparison between the 2011 and the 2007 Appropriateness Use Criteria for Echocardiography

Epicardial Adipose Tissue Relating to Anthropometrics, Metabolic Derangements and Fatty Liver Disease Independently Contributes to Serum High-Sensitivity C-Reactive Protein Beyond Body Fat Composition: A Study Validated with Computed Tomography

Neonatology Concerns about the TNE Consensus Statement

Neonatal Echocardiography—Different Approaches in Different Continents: Reply to a Letter by Evans and Kluckow

Right Ventricular Function Parameters in the Neonatal Population

Assessment of Right Ventricular Function in Targeted Neonatal Echocardiography: Reply to Letter by Dr. Koestenberger and Dr. Ravekes

Table of Contents

Editorial Board

Information for Authors

Information for Readers

ASE 2012: Taking the Best of the Past and Making It Better!

CPT, CMS, RUC, RBRVS: Why This Alphabet Soup—and Filling Out Surveys—Matters to You and Your Practice!

Continuing Education and Meeting Calendar

A New Career Ladder for Sonographers

Keeping Current in Vascular Imaging