Implementing New Technology
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1 Implementing New Technology PP16 Imaging Conference Bicol Hospital, Legaspi City, Philippines July 2016 David Adams, ACS, RCS, RDCS, FASE Duke University Medical Center
2 Echo Evolution By Dr. Zoghbi Handheld/POC echo LIVE 3D TEE Speckle Tracking LIVE 3D Tissue Doppler Contrast/Harmonics TEE Color Doppler Doppler 2 Dimensional M-mode A-mode
3 Scary Evolution 3
4 New Technology Requires New Questions 4
5 1 st What we are NOT Covering 5
6 Physics DUKE: Adams
7 Knobology DUKE: Adams
8 More why than how! 8
9 Questions Who routinely does 3D? Who does strain imaging? DUKE: Adams
10 Question Why should you care? DUKE: Adams
11 The Goal of Echo? Gives you a job Makes money for the lab Makes money for IAC To make a diagnosis To get the pt to therapy
12 Todays Talk Speckle Strain 12
13 Echo Technology My Interpretation 13
14 It takes a strong man to make a tender chicken Frank Perdue 14
15 It takes an aroused man to make a chicken affectionate Spanish translation 15
16 History of Echo One Slide 16
17
18 Questions for any New Technology Does it help you get thru the day? It is reproducible? Is it the same across Vendors? EF is Longitudinal strain is (kind of) Others not
19 Strain Case 32 y/o F Breast CA dx 2012 Older Sister dx d 2010 Started on chemotherapy adriamycin Concern = cardiotoxicity
20 Chemo pt
21 Strain #1 during chemo
22 Strain #2 post change
23 Chemo pt Strain #1 vs 2 GS = -11% GS = -20%
24 We will come back to this patient.
25 Strain s Bottom Line Strain changes before EF changes Serial studies tracking small changes over time
26 Strain pattern recognition Good Bad
27 Strain Not for sissies Confusing Strains the brain My Goal simplify Echo s goal get the pt to therapy Strain is just another tool
28 Some New Terms Parametric imaging Measuring things the eye can t see Requires special software
29 Parametric displays Good Bad
30 Some New Terms Parametric imaging Measuring things the eye can t see Requires special software Speckle
31 Speckle Acoustic signature within tissue Myocardium = lots of speckles A kernel is a defined area of speckle
32 Some New Terms Parametric imaging Measuring things the eye can t see Requires special software Speckle Speckle-Tracking (STE)
33 Speckle tracking
34 Speckle tracking Acoustic signature within tissue Myocardium = lots of speckles A kernel is a defined area of speckle
35 Strain software Identifies, tracks and displays speckle patterns (kernels) in the myocardium Why should you care (besides having a new toy) Helps clinically: Chemo pts more sensitive than EF HCM / amyloid CRT CAD & Valvular Disease
36 Strain Deformation dealing with shape and volume change Distance between speckle kernels changes
37 Strain During contraction (systole) in the long axis speckle gets closer (negative) longitudinal strain
38 Strain During contraction (systole) in the long axis speckle gets closer (negative) In the short axis the speckle moves away (positive) radial strain
39 3 Types of Strain Radial Circumferentia l Longitudinal
40 Longitudinal Strain Negative Unitless (percentage) Normal (-19 or 20%)
41 Getting started 2D Images Required: Apical 4 chamber Apical 2 chamber Apical Long
42 Examples: 2D images Not all patients have studio quality images, and it still tracks!!!
43 How to perform a Speckle- Tracking Strain Echocardiogram 2D Images Required: Apical 4 chamber Apical 2 chamber Apical Long Doppler images Required (for AoV closure timing): CW through AoV PW of LVOT
44 Example: Spectral Doppler Measure on the valve clicks (for CW or PW as applicable)
45 Why do we care about AoV closure? Contraction after AoV closure is wasted energy.
46 Why do we care about frame rate? Frame rate of 60-90Hz < 60 Hz kernels move too much > 90 Hz kernels don t move enough
47 Analysis Check the waveforms! Do they make sense? What do they mean? What are the other things shown in the analysis?
48 Good tracking
49 Bad tracking (stupid)
50 Waveforms EKG AVC Waveforms trace the regional strain throughout the cardiac cycle
51 Waveforms & colors
52 Analysis continued: M-Mode AVC Colors represent the movement of the speckles throughout the cardiac cycle
53 Normal LS? GS = -19%
54 Example: End Products Average Global Peak Longitudinal Strain: -20.1% (normal)
55 Chemo pt
56 Chemo pt Strain #1
57 Chemo pt Strain #2
58 Chemo pt Strain #1 vs 2 GS = -11% GS = -20%
59 Clinical Balancing Act Strain improved but was chemo Rx effective? Not all cardiac toxicity is irreversible. Pick your poison?
60 Amyloid pt?
61 Amyloid pt - Strain
62 Amyloid pt - Strain
63 Other Strain Applications Cardiomyopathies (in general) Hypertrophic Cardiomyopathies (HCM) Athlete s Heart Sarcoidosis, Lupus Amyloidosis Myocardial Infarction Aortic Stenosis And the list is growing!
64 More Research Strain
65 1989 MV Anatomy Dr. Bob Levine, et al at MGH 4 Chamber Long Axis
66 No MVP from Apical 4-Ch
67 Thanks to the Duke Echo Lab
68 The End DUKE: Adams
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