Echocardiography: Tools to Increase Clinical Confidence

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 Displacement Imaging on the Toshiba Aplio XG graphically displays correct timing sequence with pacemaker optimization. At right, the graph depicts quantification of wall displacement.

In 50 years, echocardiography has gone from a single dimensional view of the heart to a 3D and even 4D real-time technique. Adding to echo’s sophistication are quantitative analysis, greater portability, better workflow and efficient information management.

Three things are converging to make echocardiography better: Image quality keeps improving, applications are faster and networked systems are smaller and more portable. Portable machines provide echo, email, and a workstation in one laptop so tests can be done anywhere, stored, and then communicated back to the department. State-of-the art ultrasound systems no longer live in just large boxes. And in the next couple of years, the size of echo systems will shrink even further to be a bit larger than an iPod and offer excellent image quality.

Building clinical confidence is a major piece of the echocardiography puzzle. Labs around the country are utilizing the latest technologies, ultimately allowing physicians to make a more confident diagnosis.


Better efficiency



Dennis Atherton is the director of non-invasive cardiology at Maine Medical Center in Portland. He and his team perform adult and pediatric echocardiography on premature infants under 1 kilogram to adults over 600 pounds—presenting a variety of challenges. Last year, the hospital performed approximately 10,000 echo exams.

To get the most accurate read, Atherton obtains 3D data and strain data on every patient using the IE33 from Philips Medical Systems. He finds that Tissue Doppler Imaging (TDI) Quantification allows clinicians to better diagnose coronary artery disease, and assess cardiovascular anatomy and LV function with more accuracy. Strain imaging assists in detecting wall motion abnormalities and contrast improves imaging, enabling perfusion data to be obtained. Atherton says the new digital capabilities have greatly improved their efficiency: Pathology can be quickly identified and interrogated, and when speed and accuracy are essential—such as in a trauma room setting—his team is able to provide it.

“If you cannot see it, you cannot make the diagnosis,” says Atherton. “The single crystal in the system provides the best image with the broadest imaging frequency that I have seen in my 25 years of scanning.” That PureWave crystal technology provides greater sensitivity in harmonic imaging, improving penetration in difficult patients. Now sonographers and clinicians can quickly obtain the required images and then analyze the raw data later. The user also can change settings and measurements on the images to verify or correct the work that has been prepared.


Quantify, quantify, quantify


Quantification of traditionally difficult tasks such as ejection fraction and wall motion give the skilled reader more data, making the overall study more accurate and reproducible. With a higher degree of clinical confidence, the physician has more time to focus on diagnosis and patient management.

Randolph Martin, MD, is a cardiologist at Emory University Hospital in Atlanta—where he scans both complex adult patients and those with congenital heart disease. Emory is a 587-bed facility specializing in the care of acutely ill adults. Martin says quantitative analysis is one of the best improvements in echo to date.

“Until now, echo has mostly been qualitative—through the experienced eye of the reader—but to be quantitative, we’re adding a level of tremendous sophistication to our diagnoses,” says Martin. “The ability to use automated 3D volumes and automated ejection fractions and to quantitate global and regional strain has been extremely useful.”

Using the Vivid 7 from GE Healthcare, Martin measures patients with heart failure, patients who have had myocardial infarct and complications of that, and patients with very complex congenital abnormalities. “Echo provides amazing diagnostic information across the gamut of disease states,” he says. “And because it is three-dimensional, we think it aids us greatly in making a better diagnosis.” Martin believes that there will be further quantification of not only the function of the heart, but early detection of disease states before they clinically manifest.


Image is everything


Storing images digitally allows users to move them around, manipulate them, and then send them to specialists such as cardiac surgeons who can review them from a workstation before a procedure. At The Iowa Heart Center, Paula Carr is the technical director in charge of evaluating, reviewing and purchasing technology for the hospital. The facility is composed of a large private cardiology practice with six full-time clinics throughout Iowa and 30 outreach clinics in Iowa and Missouri. Together they perform more than 10,000 echocardiograms, transesophageal echocardiograms (TEE) and stress echos annually.

In the last decade, Carr says she has seen significant improvements in image quality. “It just keeps getting better,” she says. All studies at Iowa Heart are done digitally with images based on cardiac cycles using Toshiba America Medical Systems’ Aplio, Aplio XG and Xario systems. “With digital, things became simpler,” she says. “Now with the addition of tissue harmonics, it’s easier to image large or difficult-to-scan patients because it improves resolution and increases accuracy.”

“Using 2D echo technology with the enhanced features such as physiologic color flow analysis, pulse wave and continuous wave Doppler help to take away subjectivity,” Carr says. She can do studies with more ease and speed, putting the patient more at ease, too. A one-touch optimization feature automatically optimizes 2D gain level by evening out the gains throughout the view, then cleaning up that image. Once studies are completed, the calculations automatically transfer into structured reports that are saved on the network, so a physician can pull up the study at any time. Structured reports are easier to read and understand, and because these e-records are stored in the network; the hospital is improving echo workflow.

Carr says she is waiting for 4D imaging to come of age and she also is closely watching Speckle tracking. With speckle tracking, tissue velocities can be obtained of segments at various angles to the ultrasound beam, allowing for more accurate assessment of left ventricular mechanics.


Portability, real time, sophistication


Mani Vannan, MD, a cardiologist at University of California at Irvine performs about 25,000 echos each year. He says the portability, real time and sophistication of echo will remain unparalleled by any other technique for a long time. “My trade is all about images, that’s who I am. I read images; I interpret images, so the highest quality is one of the main foundations of providing the right information as well,” he says.

Workflow—or knowledge-based imaging capabilities—is incredibly important. The ability to store, acquire, review and transfer images simply makes the process easier and the hospital more efficient. With Siemens Medical Solutions Acuson Sequoia echocardiography platform, patient measurements and data are seamlessly transferred into the network after a study. “I don’t need to measure things or enter numbers, so I’m saving time and focusing more on diagnosis,” says Vannan. The system also auto-populates report fields, speeding report times for referring clinicians and alleviating possible errors in transferring numbers. “The hallmark for me is the ease of workflow with high image quality.”

With greater portability, interpretation for knowledge-based imaging, and absolute real-time 3D, intelligent echocardiography gives doctors better tools to make the most knowledgeable diagnosis.