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Cases from the Guidelines

Course on comprehensive applications of the EAE/ASE recommendations in the clinical arena Course organised jointly with ASE

Non-invasive Imaging: Echocardiography

This session was co-chaired by Rosa Sicari and myself and was aimed at bringing the various Guideline and Recommendation documents to life by illustrating them with cases showing practical application of the documents.

The first talk was delivered by Sanjiv Kaul from Portland in the US.  Professor Kaul is one of the Godfathers of Contrast Echo and he elegantly used his vast experience to draw on cases that really highlighted how contrast changed the diagnosis and management in multiple situations. These cases ranged from application to patients presenting with chest pain in the emergency room, to the differential diagnosis of thrombus from intra-cardiac tumours. Sanjiv concluded by providing some practical hints and tips for the application of contrast and by highlighting the point that, in his institution, Contrast is used in 100% of stress cases.

I gave the second talk which used several cases to illustrate the recommendations for clinical application of 3D which have recently been published. I started with a case of a patient receiving herceptin treatment for breast cancer. This case demonstrated how 3D assessment of left ventricular ejection fraction was able to track her LV function over an 18 month period with little variability, whereas when 2D biplane measurement were used, the variability between measurement points exceeded the 10% that is normally considered as the cut-off for terminating treatment. I also demonstrated a case of 3D assessment of mitral stenosis and how important 3D transoesophageal echocardiography has become during structural interventions. I used a case of closure of a mitral paravalvular leak, which could not have been accomplished without 3D guidance.

The third talk from Alexandra Goncalves from Portugal followed on nicely in that it concentrated on the recent Guidelines for the use of Echo during structural interventions for valvular disease. Alexandra showed some beautiful cases, which included complications of TAVI procedures assessed by Echo. In addition, she demonstrated an excellent Valve in Valve case where Echo was pivotal in guiding the procedure. Alexandra’s images were stunning and as she continued with cases of paravalvular regurgitation, mitra-clip, septal ablation in patients with hypertrophic obstructive cardiomyopathy and complex atrial septal defect closure she left the audience in no doubt that the role of the Echocardiographer is expanding. There is now a new subspecialty of Interventional Echocardiography and the new recommendations provide timely guidance to those of us working in that field.

The final presentation was made by Angie Brown from Ireland.  Angie showed the audience a large number of stress echo cases which had been carefully chosen to highlight important teaching points. Each case had great images and a simple, but different message. We saw examples of stress echo used for the diagnosis of coronary disease and for risk stratification in patients undergoing major surgery. In addition, Angie provided a comprehensive history and follow-up for each case which helped put them all in clinical context.
The guidelines do not focus exclusively on the use of stress in coronary artery disease and Angie used a number of valve disease cases to make that point and to show how the technique can be used to assess the significance of valve lesions. These cases dovetailed well with some of the previous examples of structural interventions for valve lesions.


The session was well attended and could have gone on for much longer. I think it highlighted how popular case based presentations are and they can make even potentially boring documents interesting!




Cases from the Guidelines

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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