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EACVI Echocardiography Textbook - sample

Discover the EACVI Textbook of Echocardiography 2nd edition

Chapter 13 Stress

Chapter 13 Stress echocardiography: image acquisition and modalities Rosa Sicari, Edyta Płońska-Gościniak, and Jorge Lowenstein Contents General test protocol 96 Specific protocol: deformation echocardiography 96 Contrast echocardiography: left ventricular opacification 97 Coronary flow reserve 97 Three-dimensional stress echo 97 References 98 General test protocol During stress echo, electrocardiographic leads are placed at standard limb and precordial sites, slightly displacing (upward and downward) any leads that may interfere with the chosen acoustic windows. A 12-lead ECG is recorded in the resting condition and each minute throughout the examination. An ECG lead is also continuously displayed on the echo monitor to provide the operator with a reference for ST-segment changes and arrhythmias. Cuff blood pressure is measured in the resting condition and each stage thereafter. Echocardiographic imaging is typically performed from the parasternal long- and short-axis, apical long-axis, and apical four- and two-chamber views. In some cases the subxiphoidal and apical long-axis views are used. Images are recorded in the resting condition from all views and captured digitally. A quad-screen format is used for comparative analysis. Echocardiography is then continuously monitored and intermittently digitally stored. In the presence of obvious or suspected dyssynergy, a complete echo examination is performed and recorded from all possible approaches to allow optimal documentation of the presence and extent of myocardial ischaemia. These same projections are obtained and digitally stored during the recovery phase, after cessation of stress (exercise or pacing) or administration of the antidote (aminophylline for dipyridamole, beta-blocker for dobutamine, nitroglycerine for ergometrine) [1], an ischaemic response may occasionally occur later, after cessation of drug infusion [1]. In this way, the transiently dyssynergic area during stress can be evaluated by a triple comparison: stress versus resting state, stress versus recovery phase, and at peak stress. It is critical to obtain the same views at each stage of the test. Analysis and scoring of the study are usually performed using a 16- or 17-segment model of the left ventricle [1] and a four-grade scale of regional wall motion analysis (% Table 13.1). Specific protocol: deformation echocardiography The state-of-the art diagnosis of ischaemia in stress echocardiography remains the eyeballing interpretation of regional wall motion in black and white cine-loops. However, the major limitation of this approach is the subjective interpretation requiring dedicated training and experience. Speckle tracking echocardiography (STE) is a relatively new, angle-independent technique used for the evaluation of cardiac function. This technique [2] can theoretically be used in any myocardial section. The tracking system is based on grey-scale B-mode images. The deformation is automatically obtained during the cardiac cycle from the distance between two pixels of a myocardial segment. The tracking

Chapter 14 Stress echocardiography: diagnostic criteria and interpretation Paolo Colonna, Monica Alcantara, and Katsu Tanaka Contents Semiology: wall motion response to stress 99 Viability 100 Ischaemia 100 Limited coronary flow reserve 101 Localization of coronary artery lesions 102 False positive 102 False negative 102 References 103 Semiology: wall motion response to stress During physical and inotropic stress the regional wall motion and thickening increases in normal subjects; in the same manner the ejection fraction increases mainly because of a reduction of end-systolic volume. Conversely, in patients with coronary artery disease a stress-induced regional systolic dysfunction is usually observed. Despite the development of novel techniques for quantitation of stress echocardiography, the standard approach to diagnostic criteria and the interpretation of stress echocardiograms continues to be based on a qualitative assessment of regional wall motion before, during, and after stress [1]. It is highly recommended to follow a systematic step-by-step approach to the interpretation of stress echocardiography to reduce subjectivity and to improve the reproducibility of the test. The reading should begin with the evaluation of images at rest, observing left ventricular (LV) regional wall motion and thickening, as well as LV shape and size, in order to detect patients with abnormal global LV function. The regional systolic wall function is characterized by wall thickening and endocardial inward motion [2]. In clinical practice, the regional function of each myocardial segment of the LV is visually evaluated using a qualitative score according to the joint recommendations from the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI; formerly the European Association of Echocardiography) [3]: normokinesia (normal inward motion and normal thickening), hypokinesia (reduced but not absent inward motion and thickening), akinesia (absent inward motion and thickening), and dyskinesia (systolic outward motion of the ventricular wall). It is recommended that each segment should be analysed individually and scored on the basis of its motion and systolic thickening; moreover, the function of each segment should be confirmed in multiple views, in order to obtain the correct localization of an eventual coronary artery lesion. A special difficulty in visual qualitative analysis relates to segments with poor visibility in which there is pronounced uncertainty about the correct assessment of function. Application of left heart contrast agents enhances visibility of endocardial systolic motion and thereby improves accuracy of function analysis as well as agreement between different observers on regional function analysis [4,5]. Besides qualitative subjective analysis, several approaches for objective quantification of regional systolic function have been suggested with myocardial deformation imaging,

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