[Show abstract][Hide abstract] ABSTRACT: The impact of echocardiography on the continuum of cardiovascular health care is well established. Ongoing concerns regarding costs, accessibility, quality, and appropriateness of services rendered by practitioners of echocardiography have prompted various legislative proposals and regulatory policies from government, medical professional groups, and health plans. Specifically, there continues to be a drive to enact law for licensure of sonographers. These activities require continuing advocacy for the profession with active leadership. As part of its mission statement, the American Society of Echocardiography (ASE) states, "ASE strives to be a leader in public policy in order to create a favorable environment for excellence in the practice of echocardiography." As such, the ASE is committed to an increase in their interaction with legislators, payers, and policy makers. This article describes the historical perspective of state, federal, and provincial sonographer licensure issues to provide an understanding of the political perspectives.
Journal of the American Society of Echocardiography 01/2002; 14(12):1212-9. · 3.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In 1992, the American Society of Echocardiography published a report of the Sonographer Education and Training Committee's recommendations for education of sonographers who perform echocardiographic procedures. Since the publication of the original document, there has been continual progress in technology with the development of more sophisticated diagnostic applications that allow more information to be obtained from echocardiographic procedures. These recent changes in the clinical application of echocardiography should be included in all cardiac sonographer education programs. The American Society of Echocardiography, a professional society that currently represents approximately 2500 cardiac sonographers, provides these updated guidelines.
Journal of the American Society of Echocardiography 02/2001; 14(1):77-84. · 3.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The goal of this study was to examine the ability of physical examination to predict valvular aortic stenosis severity and clinical outcome in 123 initially asymptomatic subjects (mean age 63 +/- 16 years, 70% men) followed up for a mean of 2.5 +/- 1.4 years.
Doppler aortic jet velocity correlated with systolic murmur intensity (P =.003) and timing (P =.0002), a single second heart sound (P =.01), and carotid upstroke delay (P <.0001) and amplitude (P <.0001). However, no physical examination findings had both a high sensitivity and a high specificity for the diagnosis of severe valvular obstruction. Clinical end points were reached in 56 subjects (46%), including 8 deaths and 48 valve replacements for symptom onset. Univariate predictors of outcome included carotid upstroke delay (P =.0008) and amplitude (P =.0006), systolic murmur grade (P <.0001) and peak (P =.0003), and a single second heart sound (P =.003). On multivariate Cox regression analysis, the only physical examination predictor of outcome was carotid upstroke amplitude (P =.0001).
Although physical examination findings correlate with stenosis severity, echocardiography still is needed to exclude severe obstruction reliably when this diagnosis is suspected.
American Heart Journal 02/1999; 137(2):298-306. · 4.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Three-dimensional echocardiography has demonstrated superiority over two-dimensional techniques in the determination of left ventricular mass and volumes. We describe a technique based on a magnetic tracking system which provides rapid three-dimensional image acquisition from multiple acoustic windows. Interactive three-dimensional border tracking and reconstruction with a piecewise smooth subdivision model accurately reproduced phantom volume (calculated volume = 1.00 true volume - 0.6 ml, r = 1.000, standard error of the estimate = 1.3 ml), in vitro heart volume (calculated volume = 1.02 true volume - 1.3 ml, r = 1.000, standard error of the estimate = 0.4 ml), in vitro heart mass (calculated mass = 0.98 true mass + 1.4 gm, r = 0.998, standard error of the estimate = 2.5 gm), and in vivo stroke volume (calculated stroke volume = 1.18 Doppler stroke volume - 17.9 ml, r = 0.990, standard error of the estimate = 2.8 ml). The three-dimensional in vivo data sets, which include views from three acoustic windows, were acquired in less than 90 seconds. We conclude that this method of three-dimensional echocardiographic data acquisition and analysis overcomes limitations inherent in currently available systems.
Journal of the American Society of Echocardiography 11/1997; 10(8):830-9. · 3.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Only limited data on the rate of hemodynamic progression and predictors of outcome in asymptomatic patients with valvular aortic stenosis (AS) are available.
In 123 adults (mean age, 63 +/- 16 years) with asymptomatic AS, annual clinical, echocardiographic, and exercise data were obtained prospectively (mean follow-up of 2.5 +/- 1.4 years). Aortic jet velocity increased by 0.32 +/- 0.34 m/s per year and mean gradient by 7 +/- 7 mm Hg per year; valve area decreased by 0.12 +/- 0.19 cm2 per year. Kaplan-Meier event-free survival, with end points defined as death (n = 8) or aortic valve surgery (n = 48), was 93 +/- 5% at 1 year, 62 +/- 8% at 3 years, and 26 +/- 10% at 5 years. Univariate predictors of outcome included baseline jet velocity, mean gradient, valve area, and the rate of increase in jet velocity (all P < or = .001) but not age, sex, or cause of AS. Those with an end point had a smaller exercise increase in valve area, blood pressure, and cardiac output and a greater exercise decrease in stroke volume. Multivariate predictors of outcome were jet velocity at baseline (P < .0001), the rate of change in jet velocity (P < .0001), and functional status score (P = .002). The likelihood of remaining alive without valve replacement at 2 years was only 21 +/- 18% for a jet velocity at entry > 4.0 m/s, compared with 66 +/- 13% for a velocity of 3.0 to 4.0 m/s and 84 +/- 16% for a jet velocity < 3.0 m/s (P < .0001).
In adults with asymptomatic AS, the rate of hemodynamic progression and clinical outcome are predicted by jet velocity, the rate of change in jet velocity, and functional status.
[Show abstract][Hide abstract] ABSTRACT: This study was designed to investigate the effect of altering transvalvular volume flow rate on indexes of aortic stenosis severity (valve area, valve resistance, percent left ventricular stroke work loss) derived by using Doppler echocardiography.
Assessment of hemodynamic severity in aortic stenosis has been limited by the absence of an index that is independent of transvalvular flow rate. The traditional measurement of valve area by the Gorlin equation has been shown to vary with alterations in transvalvular flow. Recently, valve resistance and percent stroke work loss have been proposed as indexes that are relatively independent of flow. Although typically derived with invasive measurements, valve resistance and percent stroke work loss (in addition to continuity equation valve area) can be determined noninvasively with Doppler echocardiography.
We performed 110 symptom-limited exercise studies in 66 asymptomatic patients with valvular aortic stenosis. Continuity equation valve area, valve resistance (the ratio between mean transvalvular pressure gradient and mean flow rate) and the steady component of percent stroke work loss (the ratio between mean transvalvular pressure gradient and left ventricular systolic pressure) were assessed by Doppler echocardiography at rest and immediately after exercise.
Mean transvalvular volume flow rate increased 24% (from [mean +/- SD] 319 +/- 80 to 400 +/- 140 ml/s, p < 0.0001); mean pressure gradient increased 36% (from 30 +/- 14 to 41 +/- 18 mm Hg, p < 0.0001); continuity equation aortic valve area increased 14% (from 1.38 +/- 0.50 to 1.58 +/- 0.69 cm2, p < 0.0001); valve resistance increased 13% (from 137 +/- 81 to 155 +/- 97 dynes.s.cm-5, p < 0.0001); and percent stroke work loss increased 17% (from 17.4 +/- 6.9% to 20.3 +/- 8.5%, p < 0.0001). The effects of flow on valve area, valve resistance and percent stroke work loss were independent of the presence of an aortic valve area < or = or > 1.0 cm2 or reduced transvalvular flow rate (rest cardiac output < 4.5 liters/min).
In patients with asymptomatic aortic stenosis, Doppler echocardiographic measures of valve area, valve resistance and percent stroke work loss are flow dependent. Flow dependence is observed with valve area < or = or > 1.0 cm2 and in the presence of both normal and low transvalvular flow states. The potential effects of transvalvular flow should be considered when interpreting Doppler measures of aortic stenosis severity.
Journal of the American College of Cardiology 11/1994; 24(5):1342-50. · 15.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Valve areas derived by the Gorlin formula have been observed to vary with transvalvular volume flow rate. Continuity equation valve areas calculated from Doppler-echo data have become a widely used alternate index of stenosis severity, but it is unclear whether continuity equation valve areas also vary with volume flow rate. This study was designed to investigate the effects of changing transvalvular volume flow rate on aortic valve areas calculated using both the Gorlin formula and the continuity equation in a model of chronic valvular aortic stenosis.
Using a canine model of chronic valvular aortic stenosis in which anatomy and hemodynamics are similar to those of degenerative aortic stenosis, each subject (n = 8) underwent three studies at 2-week intervals. In each study, transvalvular volume flow rates were altered with saline or dobutamine infusion (mean, 10.3 +/- 5.1 flow rates per study). Simultaneous measurements were made of hemodynamics using micromanometer-tipped catheters, of ascending aortic instantaneous volume flow rate using a transit-time flowmeter, and of left ventricular outflow and aortic jet velocity curves using Doppler echocardiography. Valve areas were calculated from the invasive data by the Gorlin equation and from the Doppler-echo data by the continuity equation. In the 24 studies, mean transit-time transvalvular volume flow rate ranged from 80 +/- 33 to 153 +/- 49 mL/min (P < .0001). Comparing minimum to maximum mean volume flow rates, the Gorlin valve area changed from 0.54 +/- 0.22 cm2 to 0.68 +/- 0.21 cm2 (P < .0001), and the continuity equation valve area changed from 0.57 +/- 0.18 cm2 to 0.70 +/- 0.20 cm2 (P < .0001). A strong linear relation was observed between Gorlin valve area and mean transit-time volume flow rate for each study (median, r = .88), but the slope of this relation varied between studies. The Doppler-echo continuity equation valve area had a weaker linear relation with transit-time volume flow rate for each study (median, r = .51).
In this model of chronic valvular aortic stenosis, both Gorlin and continuity equation valve areas were flow-dependent indices of stenosis severity and demonstrated linear relations with transvalvular volume flow rate. The changes in calculated valve area that occur with changes in transvalvular volume flow should be considered when measures of valve area are used to assess the hemodynamic severity of valvular aortic stenosis.
[Show abstract][Hide abstract] ABSTRACT: The anatomy of degenerative valvular aortic stenosis has been poorly represented in animal models, limiting the evaluation of noninvasive echo-Doppler measures of transvalvular volume flow rate and stenosis severity during progressive disease evolution or under conditions of changing volume flow rates. To study these issues, chronic valvular aortic stenosis, characterized by stiff leaflets without commissural fusion, was created in nine adult mongrel dogs by suturing pericardial covered Teflon-felt pads into the sinuses of Valsalva below the coronary ostia during hypothermic cardiac arrest. In the eight surviving dogs, echo-Doppler examinations were performed weekly for up to 8 wk postoperatively. Simultaneous invasive micromanometer pressure data were collected at 2-wk intervals in all subjects, with simultaneous ascending aortic transit time-volume flow measurement in four subjects. Volume flow rates were altered with saline and dobutamine infusions during invasive studies for comparison of echo-Doppler and invasive pressure gradients, volume flow, and valve areas. Serial echo-Doppler follow-up (39 +/- 11 days) demonstrated that, from baseline to final study, mean transvalvular pressure gradient increased (4 +/- 1 to 38 +/- 7 mmHg, P = 0.001), continuity equation aortic valve area decreased (2.06 +/- 0.18 to 0.54 +/- 0.04 cm2, P < 0.0001), and progressive left ventricular hypertrophy developed (62 +/- 6 to 114 +/- 9 g, P = 0.0003). Echo-Doppler and invasive data correlated well for measures of transvalvular pressure gradients (n = 98, maximum instantaneous gradient r = 0.95, mean gradient r = 0.91), volume flow (n = 75, stroke volume r = 0.86, cardiac output r = 0.86), and valve area (n = 73, r = 0.73) despite acute alterations in volume flow and progressive disease evolution. This chronic canine model, with anatomy and hemodynamics similar to clinical degenerative valvular aortic stenosis, should provide a valuable tool for investigating clinically relevant new measures of stenosis severity with use of invasive or noninvasive techniques.
The American journal of physiology 12/1993; 265(5 Pt 2):H1734-43. · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Myocardial free wall rupture accounts for between 8% and 17% of mortality after myocardial infarction. In up to 40% of cases death occurs subacutely over a matter of hours, not minutes. Illustrative clinical cases and data suggest that a high degree of clinical suspicion, along with the early use of echocardiography, could significantly reduce mortality resulting from myocardial free wall rupture complicating myocardial infarction. Myocardial free wall rupture should be suspected in patients with recent myocardial infarction who have recurrent or persistent chest pain, hemodynamic instability, syncope, pericardial tamponade, or transient electromechanical dissociation. In this clinical situation, emergent echocardiography showing a pericardial effusion or pericardial thrombus is highly suggestive of free wall rupture. Surgical exploration and rupture repair is the definitive diagnostic and therapeutic procedure.
American Heart Journal 11/1993; 126(4):946-55. · 4.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We hypothesized that the physiologic response to exercise in valvular aortic stenosis could be measured by Doppler echocardiography.
Data on exercise hemodynamics in patients with aortic stenosis are limited, yet Doppler echocardiography provides accurate, noninvasive measures of stenosis severity.
In 28 asymptomatic subjects with aortic stenosis maximal treadmill exercise testing was performed with Doppler recordings of left ventricular outflow tract and aortic jet velocities immediately before and after exercise. Maximal and mean volume flow rate (Qmax and Qmean), stroke volume, cardiac output, maximal and mean aortic jet velocity (Vmax, Vmean), mean pressure gradient (delta P) and continuity equation aortic valve area were calculated at rest and after exercise. The actual change from rest to exercise in Qmax and Vmax was compared with the predicted relation between these variables for a given orifice area. Subjects were classified into two groups: Group I (rest-exercise Vmax/Qmax slope > 0, n = 19) and Group II (slope < or = 0, n = 9).
Mean exercise duration was 6.7 +/- 4.3 min. With exercise, Vmax increased from 3.99 +/- 0.93 to 4.61 +/- 1.12 m/s (p < 0.0001) and mean delta P increased from 39 +/- 20 to 52 +/- 26 mm Hg (p < 0.0001). Qmax rose with exercise (422 +/- 117 to 523 +/- 209 ml/s, p < 0.0001), but the systolic ejection period decreased (0.33 +/- 0.04 to 0.24 +/- 0.04, p < 0.0001), so that stroke volume decreased slightly (98 +/- 29 to 89 +/- 32 ml, p = 0.01). The increase in cardiac output with exercise (6.5 +/- 1.7 to 10.2 +/- 4.4 liters/min, p < 0.0001) was mediated by increased heart rate (71 +/- 17 to 147 +/- 28 beats/min, p < 0.0001). There was no significant change in the mean aortic valve area with exercise (1.17 +/- 0.45 to 1.28 +/- 0.65, p = 0.06). Compared with Group I patients, patients with a rest-exercise slope < or = 0 (Group II) tended to be older (69 +/- 12 vs. 58 +/- 19 years, p = 0.07) and had a trend toward a shorter exercise duration (5.3 +/- 2.9 vs. 7.3 +/- 4.9 min, p = 0.20). There was no difference between groups for heart rate at rest, blood pressure, stroke volume, cardiac output, Vmax, mean delta P or aortic valve area. With exercise, Group II subjects had a lower cardiac output (7.4 +/- 2.4 vs. 11.5 +/- 4.6 liters/min, p = 0.005) and a smaller percent increase in Vmax (3 +/- 9% vs. 22 +/- 14%, p < 0.0001).
Doppler echocardiography allows assessment of physiologic changes with exercise in adults with asymptomatic aortic stenosis. A majority of subjects show a rest-exercise response that closely parallels the predicted relation between Vmax and Qmax for a given orifice area. The potential utility of this approach for elucidating the relation between hemodynamic severity and clinical symptoms deserves further study.
Journal of the American College of Cardiology 11/1992; 20(5):1160-7. · 15.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Determination of aortic valve area by the continuity equation is feasible and accurate but requires planimetry. Because the ratio of maximum velocities in the left ventricular outflow tract (LVOT) to aortic jet is quite similar to the ratio of velocity-time integrals at these sites, the continuity equation can be simplified by substituting maximum velocities for velocity-time integrals. Agreement with invasively determined aortic valve areas is similar with the conventional and simplified forms of the continuity equation. However, substitution of the average or sex-specific LVOT diameter for measured LVOT diameter in individual patients leads to less accurate aortic valve area determination. We conclude that simplification of the continuity equation, with measured LVOT diameter and maximum velocity and aortic jet maximum velocity, allows noninvasive calculation of the aortic valve area in a way that is simple and accurate.
Journal of the American Society of Echocardiography 01/1988; 1(2):155-7. · 3.99 Impact Factor