Pitfalls and how to avoid them
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- Eugene Snow
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1 Pitfalls and how to avoid them I.M. Coman MD, PhD, FESC
2 Pitfalls victims? WHO : all of us WHEN : - Learning curve! - Don t hurry! WHICH conditions : Poor windows Complex diseases/procedures Arrhythmias Extreme ages ( children, old pts.)
3 WHY : I. Technical errors II. Choice of irrelevant parameters III. Errors in interpreting results EAE recommendations for training, competence, and quality improvement. European Journal of Echocardiography (2009) 10,
4 A. Poor imaging
5 Change frequency! How to avoid Use harmonics!
6 How to avoid Use respiratory cycle variations /apnea! Change patient s position! Change window!
7 B. Inadequate imaging ( 2D ) A. Bad transducer position B. Wrong M-mode cut
8 How to avoid Go to the spine! ( il appice di Pordenone ) Short axis before M mode measurements!
9 Inadequate imaging ( Doppler ) Best Doppler signal....not necessarily from the ideal 2D imaging point
10 The clearest signal.. could be not the good one..
11 Inadequate imaging ( Doppler ) PW : mitral inflow 1. Bad sample volume position - valve/annulus artifacts - maximal velocity underevaluated ( modified E/A ) 2. Too large sample volume -wide velocity spectrum 3. Gain excess - may alter time and velocity measurements 4. Inadequate filters - wall / valve artifacts - falsely reduced durations
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14 Inadequate imaging ( Doppler ) 5. Inadequate Doppler beam direction - maximal velocity underevaluated 6. Sweep - greater error probability ( duration/ PHT ) 7. Number of cardiac cycles measured - > errors : pts in atrial fibrillation
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17 Inadequate imaging ( Doppler ) 8. Not using provocative maneuvers - Valsalva - respiratory - contrast 9. Ignoring audio signal 10. Lack of recording measurements
18 The chosen parameter - correctly calculated does not really express, in that context, the severity of the condition -- transmitral gradient to evaluate severity of mitral stenosis in Lutembacher syndrome -- LV/Ao gradient in aortic stenosis with low LV EF -- color ( semi quantitative ) assessment of AR in acute AR
19 low LV EF No endd. aortic turbulence.. but diastolic mitral regurge and brisk aortic PHT
20 In spite of correctly applying the technique, there are major ( nonavoidable ) disturbing factors PAP calculation using Ao/PA gradient of a PDA ( wrong angle, false > PAP ) Qp/Qs assessment of shunting if significant L/R regurge Using PAT formula for PAP assessment in very severe PHT
21 Presiune medie cateterism mm (n:6) mm (n:10) >50 mm (n:6 ) TAP (met.a) - 3,6 mm (- 14, + 8) -4,7 mm ( -16, +3) - 9,9 mm ( -21, - 5) Gradient diastolic max AP/VD ( met B.) -12,3 mm (-21-8 ) -11,9 mm ( -22, -3 ) -16,4 mm (-29,-8)
22 III. Errors in interpreting results
23 Misunderstanding results 1. Incorrect recognition of structures / waves / flows - Chiari network - protodiastolic gradients HCM - RA turbulence - paraseptal LA/RA flows versus shunting 2. Ignoring normal values range Don t be ashamed to look in a manual! 3. Not using correction for: - BMI - cardiac frequency - position : - Coanda effect - tricuspid PHT : /220 ASIA and Chiari network ( no clots! )
24 LV-RA shunting ( not tricuspid regurgitation ) Protodiastolic gradients Er, Ar in outflow tract L and R paraseptal flows no shunting
25 European Ignoring Society of Cardiology normal copyright values -All right range reserved
26 Coanda ef.: color underestimation of regurge Mitral PHT formula used for tricusp area!
27 Misunderstanding results 4. Ignoring the haemodynamic context : Associated Lesions : - transmitral gradient in associated regurge - gradient in multiple stenosis ( initial velocity high! : extended Bernoulli ) LV dysfunction : - different significance of EF in severe mitral regurge - E/A pseudonormalisation Intracavitary / arterial pressures - HT : increased color area of mitral regurge - PHT : no turbulent PDA flow
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29 Misunderstanding results 5. Recent therapeutic procedures - Diuretics - SR post electric conversion : absent or < a - stenting 6. Ignoring general biological context Age Fetal Echo - physiologic shunting - E/A < 1 Elder pts : impaired relaxation Athletic heart Hyperkinetic Syndrome - Pregnancy - Anemia - Hyperthyroidia
30 Left main stent
31 CONCLUSIONS TO AVOID PITFALLS we need : Good theoretical knowledge of US physics Solid practical training Clinical integration of data Patience
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