Transthoracic Echocardiography in Congenital Heart Disease

Details

Title

Transthoracic Echocardiography in Congenital Heart Disease

Type

Stage Two

Module code

HPS148

Requirement

Optional

Module objective

By the end of this module the Clinical Scientist in HSST will be able to analyse, synthesise, critically evaluate and apply their knowledge of echocardiography for advanced CHD in adults and children, spanning transthoracic, three- dimensional (3D) and echocardiographic techniques for the quantitative evaluation of cardiac mechanics.

Transthoracic echocardiography (TTE) will include: (i) indications for detailed paediatric echocardiogram; (ii) standardised approaches to scanning neonates, infants and children; and (iii) anatomical and functional assessment of the normal and abnormal heart.

3D echocardiography will include: (i) the indications for 3D transthoracic (3D TTE); and (ii) 3D assessment of aortic valves, atrial and ventricular septal defects

Echocardiographic techniques for the quantitative evaluation of cardiac mechanics will include: (i) techniques used to assess local wall dynamics; and (ii) physiologic measurements of left and right atrial and ventricular function.

The recommended indications for the clinical use of each technique, together with the strengths, weaknesses and limitations, will also be included. The Clinical Scientist in HSST will also be expected to apply their knowledge in their scientific and clinical practice while consistently demonstrating the attitudes and behaviours necessary for the role of a Consultant Clinical Scientist within a patient-focused service.

Knowledge and understanding

By the end of this module the Clinical Scientist in HSST will critically analyse, synthesise, evaluate and apply their expert knowledge, including:

All techniques:

• national and international recommendations and guidelines, including:
  • indications for echocardiography
  • standards for performing and reporting of echocardiograms
  • institutional accreditation for echocardiography departments
• current training guidelines and regulations for paediatric echocardiography:
  • the roles of clinical and technical leadership in echocardiography departments
  • training and supervision
• Doppler methods and their application to the assessment of cardiovascular physiology;
• echocardiographic methods available for assessment of global and regional ventricular function and the strengths and weaknesses of each technique;
• how to recognise and characterise rare and complex congenital and acquired cardiovascular abnormalities in a variety of clinical settings;
• recent advances in the field of non-invasive cardiac imaging.

Underpinning ultrasound physics, including:

The principles of:

• Doppler tissue imaging, including strain imaging;
• 3D echocardiography;
• tissue Doppler imaging (TDI);
• speckle tracking, including strain imaging;
• the role of intravascular contrast agents for opacification of the left ventricular cavity and assessment of wall motion.

3D echocardiography:

• instrumentation, including the types of matrix array transducer and how they work;
• modes of 3D data acquisition, image display including cropping, post-acquisition display, volume rendering, surface rendering, 2D multiplanar reconstruction;
• 3D colour Doppler acquisition cropping methods, orientation and display and limitations);
• transthoracic 3D examination protocol;
• management and work flow;
• assessment of the left and right ventricle, including anatomy and limitations of 2D assessment, data acquisition and cropping, orientation and display, analysis methods, clinical validation and application, future perspectives;
• mitral apparatus, the aortic and pulmonary valves and roots, and the tricuspid valve, including anatomy and limitations of 2D assessment, data acquisition, comprehensive exam, clinical validation and application, colour regurgitation;
• the right and left atria and left atrial appendage, including anatomy and limitations of 2D assessment, data acquisition, clinical validation and application;
• 3D anatomy of great vessels and their orientation in some types of CHD (e.g. double outlet right ventricle [DORV]); acquisition methods, data acquisition, analysis methods, orientation and display in multiplanar reconstruction, clinical validation and application;
• 3D stress echocardiography (acquisition methods, data acquisition, analysis methods, orientation and display, clinical validation and application);
• indications for the echocardiogram;
• limitations of 3D TTE.

Echocardiographic techniques for the quantitative evaluation of cardiac mechanics:

• terms, definitions and basic parameters of myocardial function;
• techniques used to assess local wall dynamics;
• the indications for the echocardiogram.

Tissue Doppler imaging (TDI)

TDI acquisition:

• spectral Doppler, including the settings, sample volume size and position to capture the data for the area of interest;
• colour Doppler, including how to get the highest frame rates by adjusting ultrasound settings.

TDI image analysis:

•  spectral and colour Doppler, including the different ways of displaying and post processing.

Colour Doppler measurements of myocardial function:

• velocity (v), displacement (d), strain (ε) and strain rate (SR);
• the possibility of erroneous results that arise due to poor application technique;
• the strengths and weaknesses of TDI.

Two-dimensional (2D) speckle-tracking echocardiography (STE) 2D STE image acquisition:

• how to obtain the best frame rates.

2D STE analysis of myocardial mechanics:

• the four parameters (velocity, displacement, SR and strain) of myocardial mechanics by tracking groups of intramyocardial speckles (d or v or myocardial deformation (ε or SR) in the imaging plane;
• how the assessment of 2D strain by STE can be applied to both ventricles and atria;
• longitudinal, radial and circumferential strain;
• the timing at which peak strain is measured;
• the possibility of erroneous results that arise due to poor application technique;
• the strengths and weaknesses of TDI.

Three-dimensional (3D) STE

3D STE image acquisition:

• how to obtain sufficient 3D image for 3D STE to be applied.

3D STE analysis of myocardial deformation:

• the pyramidal data sets displayed by the 3D STE software;
• the possibility of erroneous results that arise due to poor application technique;how myocardial strain and SR are sensitive parameters for quantification of diastolic function;
• strengths and weaknesses of 3D STE.

Integrated backscatter (IBS) analysis:

• IBS signal acquisition;
• IBS analysis of myocardial dynamics;
• the possibility of erroneous results that arise due to poor application technique;
• strengths and weaknesses of IBS analysis.

Physiologic measurements of left ventricular (LV) function:

• LV architecture and vectors of myocardial deformation;
• the cardiac micro and macro architecture is useful in understanding the relative contributions of different myocardial layers to the 3D components of myocardial deformation and how this information is used for optimising motion analysis using TDI and STE;
• longitudinal, circumferential mechanics, radial and twist mechanics of the heart.

Clinical use of LV displacement, velocity, strain and strain rate

LV rotation:

• ability of the LV’s rotating or twisting motion as its role in LV systolic and diastolic function;
• how to quantify LV rotational deformation by using colour TDI with high temporal resolution;
• unresolved issues and research priorities in this area.

LV dyssynchrony:

• the different techniques that can influence LV dyssynchrony;
• unresolved issues and research priorities in this area.

LV diastolic function:

• how myocardial strain and SR are sensitive parameters for quantification of diastolic function;
• unresolved issues and research priorities in this area.

Myocardial ischaemia:

• fibre thickening across the different layers of the myocardial wall to differentiate the various patterns of contractile abnormalities that may occur during acute or chronic myocardial ischaemia;
• unresolved issues and research priorities.

Fibrosis and viability:

• the detection of myocardial fibrosis and viability that is dependent on the evaluation of both myocardial tissue characteristics and myocardial shape change within the cardiac cycle;
• the various echocardiographic techniques to help diagnose fibrosis;
• normal values, published findings, unresolved issues and research priorities.

Physiologic measurements of right ventricular and left and right atrial function

Right ventricle:

• the differences between the RV and LV myocardium and their different shapes;
• the different measurements to quantitative approach to assess longitudinal RV function (tricuspid annular plane systolic excursion – TAPSE, TDI, STE);
• normal values, published findings, unresolved issues and research priorities.

Left atrium (LA):

• the four basic mechanical functions of the LA;
• global and regional LA function;
• normal values, published findings, unresolved issues and research priorities.

Right atrium (RA):

• the three phases of the RA;
• normal values, published findings, unresolved issues and research priorities.

Technical and clinical skills

By the end of this module the Clinical Scientist in HSST will have a critical understanding of current evidence and its application to the full range of advanced TTE procedures.

They will be able to perform and master each technique, adapting their response to reliably meet the varying and complex challenges that will arise and will be able to:

• perform a detailed paediatric echocardiogram consistent with European Society of Echocardiography and American Society of Echocardiography published guidelines (sequential segmental analysis);
• assess complex heart disease, including severity, timing and suitability for repair/percutaneous procedures and effects on ventricular function;
• assess complex CHD in adults;
• perform a detailed assessment in heart failure;
• perform a detailed assessment of ventricular structure and function in inherited and acquired heart muscle disease;
• assess prosthetic valve dysfunction;
• assess mechanical dyssynchrony, suitability for cardiac resynchronisation therapy and perform echo-optimisation of biventricular pacemakers.

3D echocardiography:

• perform 3D echocardiography to obtain high-quality 3D datasets, cropping and displaying the datasets to enable colleagues to understand the anatomy using a range of display methods;
• guide surgeons and interventionists during a range of anatomical repairs and closures;
• assess LV function with 3D global LV volume rendering;
• interpret the results from 3D echocardiography and generate a clinical report.

Echocardiographic techniques for the quantitative evaluation of cardiac mechanics:

• assess the effects of cardiac conditions on ventricular function;
• perform a detailed assessment of patients with heart failure by using TDI and speckle tracking on the basis of displacement measurements;
• perform a detailed assessment of ventricular structure and function in inherited and acquired heart muscle disease;
• assess mechanical dyssynchrony, suitability for cardiac resynchronisation therapy and perform echo-optimisation of biventricular pacemakers;
• interpret the results and generate a clinical report.

The Clinical Scientist in HSST will also be expected to critically reflect on their clinical practice. They will apply in practice a range of advanced clinical and communication skills to advise and communicate effectively with patients, relevant clinicians, patients and the public, and other healthcare professionals, and for each of the echocardiographic techniques in this module will be able to:

• arrange for interpreters and seek senior support where required;
• gain informed consent for each procedure as required;
• take a patient history prior to undertaking paediatric echocardiography;
• support parents, who may be extremely anxious;
• document findings accurately and concisely and interpret the results;
• discuss and communicate findings efficiently, appropriately and effectively with team members and other relevant health professionals;
• recognise when the involvement of senior medical staff is required, e.g. paediatric cardiologist, and refer appropriately;
• prepare and present echocardiographic data at clinical case conferences and scientific and clinical meetings and conferences.

Attitudes and behaviours

By the end of this module the Clinical Scientist in HSST will be expected to critically evaluate their own response to both normal and complex situations. They will consistently demonstrate the professional attributes and insights required of a Clinical Scientist in HSST working within the limits of professional competence, referring as appropriate to senior staff, and will:

• overcome communication barriers and consider social, cultural and religious perspectives without prejudging parental views;
• communicate clearly, effectively and in a timely fashion with patients, parents, carers and healthcare professionals;
• adopt a calm and empathic manner to support anxious parents and families;
• adopt a conscientious approach to all aspects of practice;
• recognise the role of each of the people involved in the diagnosis, treatment and long-term management of patients with CHD and contribute to the multidisciplinary team;
• take a leadership role in the organisation and administration of cardiac services, including training and clinical supervision;
• work collaboratively with cardiologists, cardiac surgeons, other medical staff, healthcare science practitioners, other echocardiographers, and nurses and specialists in other imaging modalities as required.