European Association of Cardiovascular Imaging survey on the evaluation of mitral regurgitation

AIMS

To evaluate the diagnosis and imaging of patients with mitral regurgitation (MR) and the management in routine clinical practice across Europe, the European Association of Cardiovascular Imaging Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of echocardiography, advanced imaging modalities, heart valve clinics, and heart valve teams was explored.

METHODS AND RESULTS

A total of 61 responders, mainly from tertiary centres or university hospitals, from 26 different countries responded to the survey, which consisted of 22 questions. For most questions related to echocardiography and advanced imaging, the answers were relatively homogeneous and demonstrated good adherence to current recommendations. In particular, the centres used a multi-parametric echocardiographic approach and selected the effective regurgitant orifice and vena contracta width as their preferred assessments. 2D measurements are still the most widely used parameters to assess left ventricular structure; however, the majority use 3D trans-oesophageal echocardiography (TOE) to evaluate valve morphology in severe MR. The majority of centres reported the onsite availability and clinical use of ergometric stress echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) imaging. Heart valve clinics and heart valve teams were also widely prevalent.

CONCLUSION

Consistent with current guidelines, echocardiography (transthoracic echocardiography and TOE) remains the first-line and central imaging modality for the assessment of MR although the complementary use of 3D TOE, CCT, and CMR appears to be growing. Heart valve clinics and heart valve teams are now widely prevalent.

EACVI survey on radiation exposure in interventional echocardiography

AIMS

The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey on radiation exposure in interventional echocardiography. The survey aimed to collect data on local practices for radioprotection in interventional echocardiography and to assess the awareness of echocardiography operators about radiation-related risks.

METHODS AND RESULTS

A total of 258 interventional echocardiographers from 52 different countries (48% European) responded to the survey. One hundred twenty-two (47%) participants were women. Two-thirds (76%) of interventional echocardiographers worked in tertiary care/university hospitals. Interventional echocardiography was the main clinical activity for 34% of the survey participants. The median time spent in the cath-lab for the echocardiographic monitoring of structural heart procedures was 10 (5-20) hours/month. Despite this, only 28% of interventional echocardiographers received periodic training and certification in radioprotection and 72% of them did not know their annual radiation dose. The main adopted personal protection devices were lead aprons and thyroid collars (95% and 92% of use, respectively). Dedicated architectural protective shielding was not available for 33% of interventional echocardiographers. Nearly two-thirds of responders thought that the radiation exposure of interventional echocardiographers was higher than that of interventional cardiologists and 72% claimed for an improvement in the radioprotection measures.

CONCLUSION

Radioprotection measures for interventional echocardiographers are widely variable across centres. Radioprotection devices are often underused by interventional echocardiographers, portending an increased radiation-related risk. International scientific societies working in the field should collaborate to endorse radioprotection training, promote reliable radiation dose assessment, and support the adoption of radioprotection shielding dedicated to interventional echocardiographers.

European Association of Cardiovascular Imaging (EACVI) survey on Cardiovascular Multimodality Imaging in Acute Myocarditis

AIMS

To assess the current role of cardiac imaging in the diagnosis, management, and follow-up of patients with acute myocarditis (AM) through an European Association of Cardiovascular Imaging survey.

METHODS AND RESULTS

A total of 412 volunteers from 74 countries responded to the survey. Most participants worked in tertiary centres(56%). All participants had access to echocardiography, while 79% and 75% had access to cardiac computed tomography (CCTA) and cardiac magnetic resonance (CMR), respectively. Less than half(47%) had access to myocardial biopsy and only 5% used this test routinely. CMR was performed within 7 days of presentation in 73% of cases. Non-ischemic late gadolinium enhancement (LGE,88%) and high-signal intensity in T2-weighted images(74%) were the most used diagnostic criteria for AM. CCTA was preferred to coronary angiography by 47% of participants to exclude coronary artery disease. Systematic prescription of beta-blockers and ACEi was reported by 38% and 32% of participants. Around a quarter of participants declared considering LGE burden as a reason to treat. Most participants (90%) reported performing a follow-up echocardiogram, while 63% scheduled a follow-up CMR. The main reason for treatment discontinuation was improvement of left ventricular ejection fraction(89%), followed by LGE regression(60%). In two-thirds of participants the decision to resume high-intensity sport was influenced by residual LGE.

CONCLUSION

This survey confirms the high utilization of cardiac imaging in AM, but reveals major differences in how cardiac imaging is used and how the condition is managed between centres, underlining the need for recommendation statements in this topic.

EACVI survey on hypertrophic cardiomyopathy

AIMS

The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate current practice for the assessment and management of patients with hypertrophic cardiomyopathy (HCM).

METHODS AND RESULTS

A total of 213 centres from 38 different countries (87% European) responded to the survey. One hundred twenty-one (57%) centres followed HCM patients in a general cardiology outpatient clinic and 85 (40%) centres in a specialized HCM/cardiomyopathy clinic. While echocardiography was the primary imaging modality, cardiovascular magnetic resonance (CMR) has become an important complementary tool. Cardiac anatomy, left ventricular (LV) systolic, and diastolic function were assessed according to current European guidelines and recommendations. To evaluate LV obstruction, 49% of the centres performed bedside provocation manoeuvres in every patient and 55% of the centres used exercise stress echocardiography. The majority of centres used the 5-year risk assessment of sudden cardiac death (SCD) calculated with the HCM Risk-SCD score. However, 34% of the centres also used extensive non-infarct late gadolinium enhancement on CMR and 27% the presence of LV apical aneurysm to help select patients for primary prevention implantable cardioverter-defibrillator therapy. Ninety-nine percent of the responding centres performed regular imaging follow-up of HCM patients.

CONCLUSION

Most centres followed European guidelines and recommendations for the diagnosis and management of patients with HCM. The importance of bedside provocation manoeuvres and exercise stress echocardiography to diagnose LV outflow obstruction requires emphasis. Additional risk markers for SCD are used in many centres and might indicate the need for an update of current European recommendations.

EACVI survey on investigations and imaging modalities in chronic coronary syndromes

Aims

The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate current practice for the assessment and management of patients with suspected and confirmed chronic coronary syndromes.

Methods and results

One-hundred and ten imaging centres from 37 countries across the world responded to the survey. Most non-invasive investigations for coronary artery disease were widely available, except cardiovascular magnetic resonance (available 40% centres). Coronary computed tomography angiography (CCTA) and nuclear scans were reported by a multi-disciplinary team in only a quarter of centres. In the initial assessment of patients presenting with chest pain, only 32% of respondents indicated that they rely on pre-test probability for selecting the optimal imaging test while 31% proceed directly to CCTA. In patients with established coronary artery disease and recurrent chest pain, respondents opted for stress echocardiography (27%) and nuclear stress perfusion scans (26%). In asymptomatic patients with coronary artery disease and an obstructive (>70%) right coronary artery stenosis, 58% of respondents were happy to pursue medical therapy without further testing or intervention. This proportion fell to 29% with left anterior descending artery stenosis and 1% with left main stem obstruction. In asymptomatic patients with evidence of moderate-to-severe myocardial ischaemia (15%), only 18% of respondents would continue medical therapy without further investigation.

Conclusion

Despite guidelines recommendations pre-test probability is used to assess patients with suspected coronary artery in a minority of centres, one-third of centres moving directly to CCTA. Clinicians remain reticent to pursue a strategy of optimal medical therapy without further investigation or intervention in patients with controlled symptoms but obstructive coronary artery stenoses or myocardial ischaemia.

EACVI survey on multimodality training in ESC countries

One of the missions of the European Association of Cardiovascular Imaging (EACVI) is 'to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging'. The future of imaging involves multimodality so each imager should have the incentive and the possibility to improve its knowledge in other cardiovascular techniques. This article presents the results of a 20 questions survey carried out in cardiovascular imaging (CVI) centres across Europe. The aim of the survey was to assess the situation of experience and training of CVI in Europe, the availability and organization of modalities in each centre and to ask for vision about potential improvements in CVI at national and European level.

EACVI survey on the evaluation of infective endocarditis

Aims

To evaluate the diagnosis and imaging of patients with suspected endocarditis and the management in routine clinical practice across Europe, the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of echocardiography, advanced imaging modalities and multidisciplinary team was explored.

Methods and results

A total of 100 European Echocardiography Laboratories from 29 different countries responded to the survey, which consisted of 20 questions. For most of the use of echocardiography and advanced imaging, answers from the centres were relatively homogeneous and demonstrated good adherence to current recommendations. In particular, two-thirds of centres report the use of a specific endocarditis team for decision-making. Echocardiography plays a key role in the diagnosis and management of endocarditis. Nuclear imaging modalities are broadly available among the centres and are mainly used in prosthetic valve endocarditis and cardiac device-related infective endocarditis. Computed tomography (CT) is widely available and used to assess for structural valve abnormalities, neurological complications, and to preoperative assessment of the coronary arteries. Most institutions provide structured patients follow-up following hospital discharge.

Conclusion

In Europe, a relatively homogenous adherence to current recommendation was observed for most diagnostic and management including the follow-up of patients with endocarditis. Decision-making is most commonly performed by a multidisciplinary team. Echocardiography remains the first line and central imaging modality for patient diagnosis and assessment, but 60% of centres also commonly use CT, whilst positron emission tomography imaging is used in patients with prosthetic valve endocarditis or device infection.

The evaluation of aortic stenosis, how the new guidelines are implemented across Europe: a survey by EACVI

Aortic stenosis (AS) is the most prevalent valvular disease in developed countries, with a prevalence that is set to expand further with an ageing population. The most recent guidelines on valvular heart disease published by the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery, aim to standardize the diagnosis and management of valvular heart diseases. The imaging criteria of the current guidelines are mostly based on EACVI Recommendations, with an appropriate diagnostic workflow being of major importance, to ensure streamlined and efficient patient assessment and accurate diagnoses and decisions regarding the timing of surgery. The EACVI Scientific Initiatives Committee, therefore, created a survey on the imaging assessment of patient with AS to investigate the diagnostic patient pathways used in different centres across Europe. In particular, we conducted this survey to better understand the use and access of advanced imaging techniques in AS including 3D transthoracic echocardiography and 3D transoesophageal echocardiography, cardiac computed tomography, and cardiovascular magnetic resonance.

Ultrasound contrast agent hypersensitivity in patients allergic to polyethylene glycol: position statement by the European Association of Cardiovascular Imaging

The Food and Drug Administration alert enhances our understanding of the mechanism of severe reactions to ultrasound-enhancing agents (UEAs). The known incidence of these reactions remains low and unchanged (1 in 10 000 administrations). Because the risk-to-benefit ratio for ultrasound contrast agents (UCAs) remains extremely low, we do not advise any changes to laboratory policy regarding indications for their use. The use of these agents should continue in situations where they have been shown to be impactful. Lipid-based UCAs (SonoVue and Luminity) are contraindicated in patients who have a history of prior hypersensitivity to these UEAs, to polyethylene glycol (PEG) (macrogol), or to PEG-containing products, such as certain bowel preps for colonoscopy or laxatives.

EACVI survey on standardization of cardiac chambers quantification by transthoracic echocardiography

AIMS

To evaluate standard reporting of cardiac chambers size and function by transthoracic echocardiography (TTE), the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of three-dimensional echocardiography (3DE) and speckle tracking-derived myocardial deformation imaging (STE) was explored.

METHODS AND RESULTS

A total of 96 European Echocardiography Laboratories from 22 different countries responded to the survey, which consisted of 20 questions. For most of the standard parameters of cardiac chamber size and function, answers from the centres were homogeneous and demonstrated good adherence to current recommendations. In particular, all centres assessed left ventricular (LV) and left atrial (LA) size combining diameter measurements with volumes obtained using the bi-plane Simpson's method. More variability was observed in the measurements of the right heart chambers and thoracic aorta. Interestingly, >90% of centres had access to 3DE and STE; however, the large majority of centres reserved the use of these techniques for selected cases, particularly for the measure of 3D LV volumes and ejection fraction and global longitudinal strain in patients being considered for cardiac device implantation, surgical intervention (valvular heart disease) or screened for cardiotoxicity. Only 10% of centres used 3DE for right ventricular and LA volumes. Also, <30% of the centres used LA strain imaging.

CONCLUSION

In Europe, a good adherence to current recommendations was observed for most of the standard parameters of cardiac chambers quantification by TTE. Advanced echocardiography modalities, such as 3DE and STE, are widely available but used only in selected cases.

Three-dimensional Echocardiography in Congenital Heart Disease: An Expert Consensus Document from the European Association of Cardiovascular Imaging and the American Society of Echocardiography

Three-dimensional echocardiography (3DE) has become important in the management of patients with congenital heart disease (CHD), particularly with pre-surgical planning, guidance of catheter intervention, and functional assessment of the heart. 3DE is increasingly used in children because of good acoustic windows and the non-invasive nature of the technique. The aim of this paper is to provide a review of the optimal application of 3DE in CHD including technical considerations, image orientation, application to different lesions, procedural guidance, and functional assessment.

Focus cardiac ultrasound: the European Association of Cardiovascular Imaging viewpoint

The concept of point-of-care, problem-oriented focus cardiac ultrasound examination (FoCUS) is increasingly applied in the settings of medical emergencies, including cardiac diseases. The European Association of Cardiovascular Imaging (EACVI) recognizes that cardiologists are not the only medical professionals dealing with cardiovascular emergencies. In reality, emergency cardiac diagnostics and treatment are also carried out by a wide range of specialists. For the benefit of the patients, the EACVI encourages any medical professional, sufficiently trained to obtain valuable information from FoCUS, to use it in emergency settings. These medical professionals need to have the necessary knowledge to understand the obtained information entirely, and to use it correctly, thoughtfully and with care. In this document, the EACVI underlines major differences between echocardiography and FoCUS, and underscores the need for specific education and training in order to fully utilize advantages and minimize drawbacks of this type of cardiac ultrasound examination in the critically ill patients.