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Echocardiography – new and evolving roles

Echocardiography plays a key role in the diagnosis of many cardiac conditions and in the assessment of response to therapy. Despite the emergence of new, advanced diagnostic tools such as cardiac computed tomography and cardiac magnetic resonance, echocardiography still plays an important role in patient care because of its unique capabilities.

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The advantages of echocardiography are that it is a safe non-invasive test without radiation exposure and is a relatively inexpensive method to rapidly evaluate the structure and functions of the heart.

The most frequent heart pathology diagnosed by echocardiography:

• advanced coronary artery disease;
• valvular heart disease;
• enlarged heart with reduced pump function;
• pericardial diseases;
• congenital heart disease.

New uses for echocardiography include :

• providing precise cardiac imaging with miniaturised transthoracic echocardiographic devices;
• three-dimensional transesophageal echocardiography for assessment of valve disease prior to surgical and transcatheter repair;
• two-dimensional and three-dimensional transesophageal echocardiography for guiding catheter-based interventions;
• playing a key role in personalised genetic medicine;
• monitoring cardiac side effects in patients undergoing chemotherapy for cancer;
• providing
perfusion imaging;
• helping in the early detection of subclinical disease.

Transesophageal echocardiography – TEE

For more precise evaluation of cardiac structures and major cardiac vessels we use TEE.

Transesophageal echocardiography examination requires cooperation of conscious patient and active swallowing of TEE probe. Depending on disease pathology that is evaluated, examination lasts from 3 to 5 minutes and is dealing only with the problem of concern.

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Indications for TEE are as follows:

• Preoperative use in unstable patients with suspected thoracic aortic aneurysms, dissection, or disruption who need to be evaluated quickly;
• Use in ICU for unstable patients with unexplained haemodynamic disturbances, suspected valve disease, or thromboembolic problems;
• Perioperative use in patients with increased risk for myocardial ischemia or infarction;
• Perioperative use in patients with increased risk of haemodynamic disturbances.

The TEE report consists of several documentations:

• Systolic function of LV, measuring volume fraction, mass of LV;
• Diastolic function of LV with regard to implied etiology of reached diagnosis;
• Detailed description of native valves or prosthetic ones, with their overall function;
• Detailed description of congenital heart disease if there was any;
• Detailed report on transplanted hearts during perioperative period
• Pericardial diseases and heart tumors;
• Detailed description of type of cardiomyopathies and therapeutic decisions.

Stress echocardiography

The atherosclerotic disease takes changes in the structure of arterial vessels derived by aging and undesirable effects of fat metabolism with the interplay of thrombocites and intrinsic humoral response. The pyramid of atherosclerotic disease can be detected at different stages and with different ultrasound tools. Stress echocardiography detects the tip of the atherosclerotic iceberg, i.e., the hemodynamically significant, ischemia-producing coronary artery stenosis through unmasking of stress-induced regional ventricular dysfunction.

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In that manner, stress echocardiography can contribute as complementary to coronarography finding, by defining more closely coronary flow reserve and myocardial function at regional level (in segmental heart model).

Pharmacological testing of myocardial function

In those we mention: dobutamine, dipyridamole, adenosine, and their combination with atropine. These are tests of coronary flow reserve and  viability.

Ergometry- Exercise test

It is categorized in functional diagnostics of the heart. It is performed either by treadmill or ergo bike, while increasing loading conditions during walking or pedal cycling.

This test can be done by different protocols. The most frequently used is Bruce`s test.

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Sportsmen have more demanding loading conditions then the rest of the population, to achieve good results in testing.

By monitoring vital parameters: frequency and blood pressure, and their oscillation and by analyzing ECG changes, compromised heart segments in regional blood flow can be detected.

Ergospirometry– Exercise test and oxygen consumption

Similar diagnostic procedure by which lung function can be also monitored.
Important in the professional sport.

Ambulatory monitoring blood pressure

AMP is diagnostic procedure of 24 hour blood pressure monitoring at every 60 min time interval. It provides precise information about mean values of systolic and diastolic blood pressure, as well as their oscillations around the day. The especial value in the analysis and interpretation has comparing these values with the diary of daily activities, mental and emotional state during 24 hours.

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In this manner we get objectified assessment of blood pressure values without psychological and/or emotional impacts of white coat, because measuring is spontaneous and recording is during sleep as well.

By pairing frequency and BP values we can calculate cardiac index which is indicator of etiology of found results (heart or other reason).


Holter ECG

Follow up of electrocardiogram tracings during 24 hours is valuable diagnostic method to evaluate frequency of heart rate and those disturbances in rhythm and conduction of electric heart impulses.

One of the possible analyses is revealing the existence of coronary heart disease.

However, it is a beneficiary method to evaluate the effects of given therapy. Therefore, it is possible to follow up medicamentous response.

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On the other hand, Holter ECG is done before the invasive electrophysiological study (in the cat lab) and implantation of permanent pace maker.

By this method we can get interpolation of all results of ECG analysis such as: heart rate variability and heart rate turbulence. These newly interesting interpolations are derived by complicated mathematical calculations (done by software) and are contributing in the follow up of stabilization in the proarrhythmic heart states (such as myocarditis).

Vectorcardiography

Highly resolutive vector analysis of QRS loop by time integral is capable of deligninig localization of tissue damage or volume overload. Much more precise than standard ECG.

By this diagnostic method very tiny damages of the heart may be visible. It is a rule out method for confirmation or rejection of some certain  heart diseases.

It may show early changes even though ECG looks normal (par exam. some cases of heart infarction or lung embolism).

Late potentials

Signal averaged ECG analysis of low frequency oscillation before and after QRS complex.

It is used in the follow up of disease progression and monitoring of therapeutic effects: proarrhythmogenic side effect even/or synergistic effect of two drugs making proarrhythmogenic milieu.

It is complementary to 24 hour ECG monitoring. It gives precise information about proarrhythmogenic features of one’s heart.

HRV (Heart rate variability)

This test duration is eighter 20min or 24 hour, depending on clinical indication. It gives numerous physiological and pathophysiological insights in a majority of internal and neural diseases.

Time domain analysis: shows proarrhytmogenic state
Frequency domain analysis: shows functioning of ANS
Non linear analysis: shows predisposition to SCD
Symbolic dynamics: shows risk for SCD

TO (Turbulence onset)

TO is a noninvasive diagnostic method intended for detecting risk of serious arrhythmia or therapeutical drug follow up or even pace maker success.

It could be used in numerous cardiovascular states, but most benefit goes to intensive care unit patients in prognostic sence.