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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Prof. Mark John Monaghan,
Thomas Buck from Essen and I chaired this well attended session. It examined a very timely issue – should we be using 3D Echo on a routine clinical basis? The consensus from the majority of speakers was YES! Professor Jens-Uwe Voigt took us through the potential benefits and disadvantages of deformation analysis using speckle tracking. He explained that 2D strain analysis is well established with lots of excellent published research. However, the heart is a complex 3D structure that moves in a complex 3D pattern, so it makes sense that we should analyse it in 3D. However it appears that there are important differences in global circumferential and radial strain values between different vendors when the same patients are examined. This is a major current limitation and disadvantage. In addition it appears that 3D strain analysis works well for the assessment of LV remodelling in patients with transmural scar, but not if the scar is not transmural. 3D radial strain analysis appears very promising however for the assessment of LV dyssynchrony and it also allows measurement of LV torsion whereas with 2D strain it is only really possible to assess LV twist. Professor Voigt’s conclusion was that at the present time, the quality and accuracy of 3D strain was not sufficient for daily practice. However, it was definitely a technique that would be needed in the future. Professor Luigi Badano from Padua discussed the role of 3D Echo during Stress studies. As he pointed out, 2D Stress Echo performs extremely well but it is time consuming, the imaging is operator dependent and the current quad screen analysis doesn’t encompass the entire LV and small segmental abnormalities may be missed. He illustrated the fact that small areas of stress induced ischaemia may be missed by 2D but demonstrated by 3D with some excellent case examples. Early 3D echo equipment was not so well suited to stress studies because of limited temporal and spatial resolution. However, Professor Badano presented interesting data from his department using contemporary 3D equipment which clearly demonstrated the value of 3D stress studies, especially when looking for apical ischaemia, which can be frequently missed in 2D studies because of foreshortening. In addition he elegantly demonstrated the display formats which can be used with 3D stress which makes interpretation easier and quicker than conventional 2D analysis. His wish list for the future included even better temporal and spatial resolution and the ability to use it in patients with irregular rhythms such as atrial fibrillation. However, the audience were left in no doubt that this is a technique that can be used clinically now and may confer significant advantages over conventional 2D stress echo. The next two presentations focussed on the use of 3D Echo (mainly TEE) during Interventional and Surgical procedures. Professor Pepe Zamorano from Madrid highlighted the role that 3D TEE now plays in the Cath Lab. Echocardiographers are now firmly established as part of the Structural Interventional team and he told us that the have now become the closest friend to the Invasive Cardiologist! Professor Zamorano focussed particularly on the use of Echo during TAVI procedures and for guiding the closure of paravalvar leaks. He explained the vital role that Echo, incorporating 3D plays in patient selection for TAVI, especially annulus sizing and assessment of aortic root morphology, including measurement of the distance between the annulus and coronary ostia. He also illustrated the important role of echo in terms of detecting complications during TAVI and demonstrated this with a number of very convincing case examples. Finally he showed some great examples of closure of mitral paravalvar leaks with 3D TEE guidance. It seems that the success of this procedure is dependent on the position of the leak – and of course, this can be readily assessed with 3D TEE. Finally, Dr Joeg Ender who is a Cardiac Anaesthesiologist from Leipzig gave an excellent demonstration of the role of Intra-operative 3D TEE. His role was to answer whether the technique was a useful tool or a toy? Using some great examples during mitral valve, thoracic and congenital surgery he clearly showed that the technique is now an essential tool during cardiac surgery. However, he highlighted that data from a recent survey in Germany demonstrated that most intra-operative TEE examinations used a limited problem focussed imaging approach because of time constraints. He felt that the lack of a full TEE exam during Intra-operative procedures could lead to important additional pathology being missed. We look forward to more data that confirms whether a focussed or full Intra-operative TEE is required in every case. This session contained excellent presentations from well-established experts in the field of 3D Echocardiography. Using great case examples and convincing data from recent studies, they illustrated that most aspects of 3D Echocardiography should now be considered main-stream and be incorporated into daily clinical practice.
Benefits of three-dimensional echocardiography in daily clinical practice
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