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Controversies in echocardiography

  • Perfusion contrast echocardiography: facts or fiction?: PRO - The Holy Grail: simultaneous perfusion and function, presented by R Senior (Harrow, GB)  
  • Perfusion contrast echocardiography: facts or fiction?: CON - In clinical practice: function yes, perfusion no, presented by G Van Camp (Brussels, BE)  
  • Who should perform emergency echo: point of no return: The non-cardiologist view, presented by F Guarracino (Pisa, IT)  
  • Who should perform emergency echo: point of no return: The cardiologist view, presented by A Hagendorff (Leipzig, DE)

First debate: Perfusion contrast echocardiography fact or fiction?

Pro:  the Holy Grail: simultaneous perfusion and function - R Senior (Harrow GB)
Con: In clinical practice: function yes, perfusion no - G Van Camp (Brussels, BE)

In this first debate, Prof R Senior begins his intervention by a short recall on contrast properties. Myocardial contrast echocardiography (MCE) has the unique capability to display blood volume (represented by the contrast that you see inside the myocardium when you look at perfusion images) but also myocardial blood velocity (when you use “flash replenishment technique”, the velocity of contrast myocardial replenishment is related to blood flow velocity). Both are altered in ischemia. Several studies have compared the diagnosis accuracy of perfusion MCE versus nuclear SPECT perfusion and conclude that both techniques are comparable. So for Prof R Senior, there is no doubt about it, this technique works! He presented several studies on the prognosis of patient with perfusion defect. In patients with suspect acute coronary syndrome, patients with perfusion defect have a worse outcome than patients with only wall motion abnormalities. In the context of viability assessment Prof R Senior demonstrated that perfusion defect by MCE was superior to contractile reserve to delineate presence of myocardial viability. This could be explained by the fact that some dysfunctional segments have very low perfusion reserve so they could not exhibit any contractile reserve under dobutamine perfusion. Nevertheless, these segment displayed perfusion on MCE images and thus must be considered as viable myocardium.  He also presented different cases of stress echocardiography where the analysis of perfusion (visual analysis) could help to reach a diagnosis and add additional information in comparison with wall motion alone.

In the second part of this debate, Prof G Van Camp stated that until now, the use of MCE for perfusion assessment has not proved its superiority in comparison to analysis of function alone for detection of coronary artery disease. The recent ESC recommendations on myocardial revascularisation do not support the use of MCE perfusion but rather the use of stress echocardiography or nuclear techniques for the diagnosis of coronary artery disease. Actually, there is no EBM (evidence base medicine) data to support the use of MCE for perfusion assessment. In the opposite, the use of MCE for left ventricular opacification (LVO) has some interest to facilitate assessment of wall motion, improve diagnosis confidence of the readers and diagnosis accuracy in patients with poor echogenic windows during regular stress echo. Prof Van Camp also stressed the problems related to the use of MCE for perfusion. First, the technique needs some expertise in the manipulation of contrast agent to avoid numerous pitfalls and artefacts. These artefacts make interpretation of perfusion in several myocardial segments difficult. If you look at the different studies on MCE perfusion, you will see that some segments are always excluded from the analysis and that the results are expressed in coronary territories rather that in segments. Secondly, real quantification of the myocardial perfusion is feasible especially in experimental settings. But in real life, most of the proposed methods are tedious and time consuming. Therefore they are not applicable in real life and most of the time a semi quantitative assessment is used. Finally, to be useful, MCE perfusion must demonstrate some cost/benefit advantage over other diagnosis technique, which we don’t have today. So his final word was: MCE for LVO: Yes for perfusion: No!

Second debate: Who should perform emergency echo: point of no return?

Pro:  The non cardiologist view - F Guarracino (Pisa IT)
Con: The cardiologist view - A Hagendorff (Lipzig, DE)

In this second debate, Prof Guarracino started his lecture by explaining that over the last decade, echocardiography has moved from the cardiology field to other specialties. Ultrasound diagnosis may help in an emergency to specify numerous diagnostic not only regarding the heart but also for vascular, abdominal and other problems. Over the last years, we also saw the arrival of handheld machines which allow for fast diagnosis but have some limitations. During the last years, the widespread of echocardiography is going along with some fast learning courses of 1 or 2 days focused on some pathology that should not be missed in the setting of an emergency department: pericardial fluid effusion, RV or LV enlargement, assessment of global LV function, use of inferior veina cava to monitor fluids. In the second part of his talk, he demonstrated that echocardiography becomes an irreplaceable tool in the assessment of critical hill patients. As an example, cardiogenic shock may have several origins and it is difficult to know the exact causes just by looking at external parameters or invasive measurements obtained by Swan Ganz catheter. But the information obtained by the echocardiography must be integrated with the clinical and local (invasive ventilation for example) data.

Prof Hagendorff redefines the landscape of “emergency echo”. It could be divided in 3 categories. First, “life treating emergencies”, where you don’t have any time and must obtain the correct diagnosis as soon as possible for correct treatment of the patient and to save his life, this is a minority of cases. Secondly, acute situation with potentially life treating situation, here you have more time to obtain the correct diagnosis. Finally, what he called “chronic” emergency, as example a patient with congestive heart failure who experiences a new episode of clinical deterioration.  So, in many circumstances, there is enough times to perform a complete comprehensive examination using the most appropriate technique (TTE or TEE) and sometimes it may be possible to use new technologies like 3D echo or MCE. Why not use “high end” ultrasound echo machines for this purpose. He specially insists on the importance to have some documentation of this first examination (written report and images). This is important because decisions are based on this first examination and may constitute a medico legal issue. There is a huge temptation to use small handheld echo machine in emergency situations but Prof Hagendorff wants to put a word of caution: image and color Doppler quality may be insufficient in several cases to allow correct diagnosis and may lead to misdiagnosis which could be harmful for the patient.

At the end of the presentations, both speakers agreed on the following points:

  • The question is not who performed the echo, but the echo must be performed by the most experienced people available at the time of the echocardiography.
  • Thus, it is of outstanding importance that echo be performed by trained people (cardiologist or other). Emphasis must be put on people training to acquire the necessary competence (what is different from focused competence acquired by focused training).
  • In emergency situation, the question is not only to scan but also to understand what you have scanned and to integrate the result with the clinical situation to make the more appropriate decision regarding the treatment.
  • If it is possible use a “high end” ultrasound system with all the capabilities. Be aware that “handheld” ultrasound systems are very attractive but have some limitations which may lead to mistakes in emergencies situation. Don’t think that “handheld” systems are more helpful in emergencies. Scanning is the easiest part of echo exam.
  • It is mandatory to report and document all the finding of this first examination because, most of the time, therapeutic decisions will be based on this first exam.




Controversies in echocardiography

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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