Kirk T. Spencer

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Focused Cardiac Ultrasound in the Emergent Setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency Physicians

The use of ultrasound has developed over the last 50 years into an indispensable first-line test for the cardiac evaluation of symptomatic patients. The technologic miniaturization and improvement in transducer technology, as well as the implementation of educational curriculum changes in residency training programs and specialty practice, have facilitated the integration of focused cardiac ultrasound into practice by specialties such as emergency medicine. In the emergency department, focused cardiac ultrasound has become a fundamental tool to expedite the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and triage decisions by the emergency physician.

Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography

1. Why is a guideline needed? 567 2. Definitions 568 a. What is FCU? 568 b. Terminology 568 3. Differentiation of FCU and ‘‘Limited TTE’’ 568 a. Examination Expectations 569 b. Equipment 570 c. Image Acquisition 570 d. Image Interpretation 570 e. Billing 571 4. Considerations for Successful Use of FCU as an Adjunct to Physical Examination 571 a. Personnel 571 b. Equipment 571 c. Potential Limitations of FCU 572 5. FCU Scope of Practice 573 a. FCU When Echocardiography is Not Promptly Available 573 b. FCU When Echocardiography is Not Practical 574

Use of harmonic imaging without echocardiographic contrast to improve two-dimensional image quality.

The aim of this study was to determine whether harmonic imaging (HI) improves endocardial visualization during 2-dimensional echocardiography without echocardiographic contrast. HI differs from fundamental imaging (FI) by transmitting ultrasound at one frequency and receiving at twice the transmitted frequency. This technique has been used in conjunction with contrast echocardiography to enhance myocardial contrast visualization. HI and FI were sequentially performed in 20 patients. Images were digitally stored and subsequently reviewed by 2 observers for the quality of endocardial visualization. In addition, acoustic quantification was performed in both FI and HI modes and endocardial tracking qualitatively judged. HI was compared with FI during dobutamine stress echocardiography in 17 patients who were imaged at baseline and peak stress. Overall, the harmonic images had less clutter and better myocardial blood contrast. Individual segments were better visualized with HI in 30% to 73% of cases. The acoustic quantification endocardial tracking was rated better with HI in 67% of short-axis views and in 58% of apical 4-chamber views. During dobutamine stress testing the overall number of interpretable segments improved from 64% for FI to 84% with HI. Many segments traditionally difficult to image were improved with HI. HI without the use of contrast agents improved endocardial visualization during routine 2-dimensional echocardiography. This improved endocardial visualization led to better endocardial tracking with acoustic quantification and to more segments being clinically interpretable during dobutamine stress testing.

Effects of aging on left atrial reservoir, conduit, and booster pump function: a multi-institution acoustic quantification study

OBJECTIVE To assess the feasibility of measuring left atrial (LA) function with acoustic quantification (AQ) and then assess the effects of age and sex on LA reservoir, conduit, and booster pump function. PATIENTS AND SETTING 165 subjects without cardiovascular disease, 3–79 years old, were enrolled by six tertiary hospital centres. INTERVENTIONS Continuous LA AQ area data were acquired and signal averaged to form composite waveforms which were analysed off-line. MAIN OUTCOME MEASURES Parameters of LA performance according to age and sex. RESULTS Signal averaged LA waveforms were sufficiently stable and detailed to allow automated analysis in all cases. An age related increase in LA area was noted. LA reservoir function did not vary with age or sex. All parameters of LA passive and active emptying revealed a significant age dependency. Overall, the passive emptying phase accounted for 66% of total LA emptying ranging from 76% in the youngest to 44% in the oldest decade. LA contraction accounted for 34% of atrial emptying in all subjects combined with the older subjects being more dependent on atrial booster pump function. When adjusted for atrial size, there were no sex related differences in LA function. CONCLUSIONS LA reservoir, conduit, and booster pump function can be assessed with automated analysis of signal averaged LA area waveforms. As LA performance varies with age, establishment of normal values should enhance the evaluation of pathologic states in which LA function is important.

Segmental analysis of color kinesis images: new method for quantification of the magnitude and timing of endocardial motion during left ventricular systole and diastole.

BACKGROUND We describe a method for objective assessment of left ventricular (LV) endocardial wall motion based on Color Kinesis, a new echocardiographic technique that color-encodes pixel transitions between blood and myocardial tissue. METHODS AND RESULTS We developed a software that analyzes Color Kinesis images and provides quantitative indices of magnitude and timing of regional endocardial motion. Images obtained in 12 normal subjects were used to evaluate the variability in each index. Esmolol, dobutamine, and atropine were used to track variations in LV function in 14 subjects. Objective evaluation of wall motion was tested in 20 patients undergoing dobutamine stress testing. Regional fractional area change, displacement, and radial shortening were displayed as histograms and time curves. Global function was assessed by calculating magnitude and timing of peak ejection or filling rates and mean time of ejection or filling. Patterns of endocardial motion were consistent between normal subjects. Fractional area change and peak ejection rate decreased with esmolol and increased with dobutamine. Time to peak ejection and mean time of contraction were prolonged with esmolol and shortened with dobutamine. Using atropine, we proved that our findings with dobutamine were not secondary to its chronotropic effects. Dobutamine induced regional wall motion abnormalities in 10 patients in 38 segments diagnosed conventionally. Segmental analysis detected abnormalities in 36 of these 38 segments and in an additional 5 of 322 segments. CONCLUSIONS Analysis of Color Kinesis images allows fast, objective, and automated evaluation of regional wall motion sensitively enough to evaluate clinical dobutamine stress data. This method has significant potential in the diagnosis of myocardial ischemia.

Characterization of degenerative mitral valve disease using morphologic analysis of real-time three-dimensional echocardiographic images: objective insight into complexity and planning of mitral valve repair.

Background—Presurgical planning of mitral valve (MV) repair in patients with Barlow disease (BD) and fibroelastic deficiency (FED) is challenging because of the inability to assess accurately the complexity of MV prolapse. We hypothesized that the etiology of degenerative MV disease (DMVD) could be objectively and accurately ascertained using parameters of MV geometry obtained by morphological analysis of real-time 3D echocardiographic (RT3DE) images. Methods and Results—Seventy-seven patients underwent transesophageal RT3DE study: 57 patients with DMVD studied intraoperatively (28 BD, 29 FED classified during surgery) and 20 patients with normal MV who were used as control subjects (NL). MVQ software (Philips) was used to measure parameters of annular dimensions and geometry and leaflet surface area, including billowing volume and height. The Student t test and multinomial logistic regression was performed to identify parameters best differentiating DMVD patients from normal as well as FED from BD. Morphological analysis in the DMVD group revealed a progressive increase in multiple parameters from NL to FED to BD, allowing for accurate diagnosis of these entities. The strongest predictors of the presence of DMVD included billowing height and volume. Three-dimensional billowing height with a cutoff value of 1.0 mm differentiated DMVD from NL without overlap, and billowing volume with a cutoff value 1.15 mL differentiated between FED and BD without overlap. Conclusions—Morphological analysis as a form of decision support in assessing MV billowing revealed significant quantifiable differences between NL, FED, and BD patients, allowing accurate classification of the etiology of MV prolapse and determination of the anticipated complexity of repair.Pre-surgical planning of mitral valve (MV) repair in patients with Barlows disease (BD) and fibroelastic deficiency (FED) is challenging due to inability to accurately assess the complexity of MV prolapse. We hypothesized that the etiology of degenerative MV disease (DMVD) could be objectively and accurately determined using morphologic analysis of MV geometry from real-time 3D echocardiographic (RT3DE) images. Seventy-seven patients underwent transesophageal RT3DE study: 57 patients with DMVD studied intra-operatively (28 BD, 29 FED classified during surgery) and 20 patients with normal MV who were used as controls (NL). Parameters of annular dimensions and geometry, and leaflet surface area were measured. Morphologic analysis in the DMVD group revealed a progressive increase in multiple parameters from NL to FED to BD, allowing for accurate diagnosis of these entities. Strongest predictors of the presence of DMVD included billowing height and volume. 3D billowing height with a cutoff value of 1.0 mm differentiated DMVD from NL without overlap, and billowing volume with a cutoff value 1.15 ml differentiated between FED and BD without overlap. Morphologic analysis as a form of decision support of assessing MV billowing revealed significant quantifiable differences between NL, FED and Barlow, allowing accurate classification of the etiology of MV prolapse and determination of the anticipated complexity of repair‥

Handcarried Ultrasound Measurement of the Inferior Vena Cava for Assessment of Intravascular Volume Status in the Outpatient Hemodialysis Clinic

Accurate intravascular volume assessment is critical in the treatment of patients who receive chronic hemodialysis (HD) therapy. Clinically assessed dry weight is a poor surrogate of intravascular volume; however, ultrasound assessment of the inferior vena cava (IVC) is an effective tool for volume management. This study sought to determine the feasibility of using operators with limited ultrasound experience to assess IVC dimensions using hand-carried ultrasounds (HCU) in the outpatient clinical setting. The IVC was assessed in 89 consecutive patients at two outpatient clinics before and after HD. Intradialytic IVC was recorded during episodes of hypotension, chest pain, or cramping. High-quality IVC images were obtained in 79 of 89 patients. Despite that 89% of patients presented at or above dry weight, 39% of these patients were hypovolemic by HCU. Of the 75% of patients who left HD at or below goal weight, 10% were still hypervolemic by HCU standards. Hypovolemic patients had more episodes of chest pain and cramping (33 versus 14%, P = 0.06) and more episodes of hypotension (22 versus 3%, P = 0.02). The clinic with a higher prevalence of predialysis hypovolemia had significantly more intradialytic adverse events (58 versus 27%; P = 0.01). HCU measurement of the IVC is a feasible option for rapid assessment of intravascular volume status in an outpatient dialysis setting by operators with limited formal training in echocardiography. There is a poor relationship between dry weight goals and IVC collapsibility. Practice variation in the maintenance of volume status is correlated with significant differences in intradialysis adverse events.

Characterization of Degenerative Mitral Valve Disease Using Morphologic Analysis of Real-Time 3D Echocardiographic Images: Objective Insight into Complexity and Planning of Mitral Valve Repair

Background—Presurgical planning of mitral valve (MV) repair in patients with Barlow disease (BD) and fibroelastic deficiency (FED) is challenging because of the inability to assess accurately the complexity of MV prolapse. We hypothesized that the etiology of degenerative MV disease (DMVD) could be objectively and accurately ascertained using parameters of MV geometry obtained by morphological analysis of real-time 3D echocardiographic (RT3DE) images. Methods and Results—Seventy-seven patients underwent transesophageal RT3DE study: 57 patients with DMVD studied intraoperatively (28 BD, 29 FED classified during surgery) and 20 patients with normal MV who were used as control subjects (NL). MVQ software (Philips) was used to measure parameters of annular dimensions and geometry and leaflet surface area, including billowing volume and height. The Student t test and multinomial logistic regression was performed to identify parameters best differentiating DMVD patients from normal as well as FED from BD. Morphological analysis in the DMVD group revealed a progressive increase in multiple parameters from NL to FED to BD, allowing for accurate diagnosis of these entities. The strongest predictors of the presence of DMVD included billowing height and volume. Three-dimensional billowing height with a cutoff value of 1.0 mm differentiated DMVD from NL without overlap, and billowing volume with a cutoff value 1.15 mL differentiated between FED and BD without overlap. Conclusions—Morphological analysis as a form of decision support in assessing MV billowing revealed significant quantifiable differences between NL, FED, and BD patients, allowing accurate classification of the etiology of MV prolapse and determination of the anticipated complexity of repair.Pre-surgical planning of mitral valve (MV) repair in patients with Barlows disease (BD) and fibroelastic deficiency (FED) is challenging due to inability to accurately assess the complexity of MV prolapse. We hypothesized that the etiology of degenerative MV disease (DMVD) could be objectively and accurately determined using morphologic analysis of MV geometry from real-time 3D echocardiographic (RT3DE) images. Seventy-seven patients underwent transesophageal RT3DE study: 57 patients with DMVD studied intra-operatively (28 BD, 29 FED classified during surgery) and 20 patients with normal MV who were used as controls (NL). Parameters of annular dimensions and geometry, and leaflet surface area were measured. Morphologic analysis in the DMVD group revealed a progressive increase in multiple parameters from NL to FED to BD, allowing for accurate diagnosis of these entities. Strongest predictors of the presence of DMVD included billowing height and volume. 3D billowing height with a cutoff value of 1.0 mm differentiated DMVD from NL without overlap, and billowing volume with a cutoff value 1.15 ml differentiated between FED and BD without overlap. Morphologic analysis as a form of decision support of assessing MV billowing revealed significant quantifiable differences between NL, FED and Barlow, allowing accurate classification of the etiology of MV prolapse and determination of the anticipated complexity of repair‥

Comparison of hand-carried ultrasound assessment of the inferior vena cava and N-terminal pro-brain natriuretic peptide for predicting readmission after hospitalization for acute decompensated heart failure.

OBJECTIVES We sought to compare the value of serial assessment with hand-carried ultrasound (HCU) of the inferior vena cava (IVC) with brain natriuretic peptide (BNP) to identify patients with acute decompensated heart failure (ADHF) who will be readmitted or seek emergency department treatment after hospital discharge. BACKGROUND Congestive heart failure (CHF) is a leading cause for hospitalization and, once hospitalized, patients with CHF frequently are readmitted. To date, no reliable index exists that can be used to predict whether patients with ADHF can be discharged with low readmission likelihood. METHODS A total of 75 patients who were admitted with a primary diagnosis of ADHF were followed. All patients were assessed at admission and discharge with the use of routine clinical evaluation, BNP measurement, and HCU evaluation of the IVC by physicians with limited training in ultrasound. RESULTS During the 30-day follow-up, 31 patients were rehospitalized or presented to the emergency department. Patients who were subsequently readmitted could not be differentiated from those who were not readmitted by their demographics, comorbidities, vital signs, presence of symptoms/signs suggestive of persistent congestion, hospital length of stay, or net volume removal. Routine laboratory tests, including assessment of renal function, also failed to predict readmission with the exception of serum sodium. Although admission BNP was similar in patients readmitted and not readmitted, pre-discharge log-transformed BNP was greater in patients who subsequently were readmitted. Patients who required repeat hospitalization had a larger IVC size on admission as well as at discharge. In addition, patients who were readmitted had persistently plethoric IVCs with lower IVC collapsibility indexes. At discharge, only serum sodium, log-transformed BNP, IVC size, and collapsibility were statistically significant predictors of readmission. CONCLUSIONS This study confirms that, once hospitalized, patients with CHF frequently are readmitted. Bedside evaluation of the IVC with a HCU device at the time of admission and discharge, as well as pre-discharge BNP, identified patients admitted with ADHF who were more likely to be readmitted to the hospital.