2D Echocardiography Case Review : Cardiac Amyloidosis

NATIONAL HEART INSTITUTE OF MALAYSIA

2D ECHOCARDIOGRAPHY

CASE REVIEW

RESTRICTIVE CARDIOMYOPATHY

CARDIAC AMYLOIDOSIS

Myocardial infiltration by amyloid fibrils can occur in primary, familial, secondary, and senile amyloidosis. The degree of involvement is variable depending upon the type of amyloidosis. Two dimensional echocardiography remains the ideal method for identifying and following individuals with cardiac amyloidosis.

Characteristic two dimensional and Doppler echocardiographic features have been described in individuals with cardiac amyloidosis. Two dimensional features include thickening of the LV walls, increased reflectivity of these walls (the ‘‘speckled’’ or ‘‘granular’’ myocardium), biatrial enlargement, thickening of the interatrial septum, thickening and regurgitation of the mitral and tricuspid valves, and the presence of a small pericardial effusion.

Transmitral Doppler flow patterns in patients with amyloidosis exhibit evidence of diastolic dysfunction. Characteristic transmitral Doppler patterns representative of early impaired relaxation and later restrictive filling have been demonstrated in this population. An increase in both the pulmonary venous Doppler atrial reversal duration and the ratio of this atrial reversal duration to the transmitral A wave duration have been observed in these patients and reflect increased LA pressure.

Cardiac amyloidosis should be considered in individuals in whom several of these echocardiographic features are observed. The coexistence of increased thickening of the LV walls on echocardiography yet low voltage on electrocardiography is highly suggestive of amyloid infiltration of the myocardium.

Differentiating cardiac amyloidosis from hypertrophic cardiomyopathy can be difficult on echocardiography. Asymmetric septal thickening can result from focal amyloid deposition and can mimic hypertrophic cardiomyopathy. The presence of decreased LV function would argue strongly against hypertrophic cardiomyopathy. The presence of highly reflective myocardium can also be seen in individuals with primary and secondary causes of LV hypertrophy, ventricular fibrosis, and other infiltrative processes.

The integration of clinical, echocardiographic, and electrocardiographic data is essential when making the diagnosis of cardiac amyloidosis. While the long term prognosis is substantially worse inmpatients with primary amyloidosis, the echocardiographic distinction between familial, primary, and secondary amyloidosis can be difficult.

Impaired LV systolic function is more common in primary amyloidosis than in the other forms. Doppler tissue echocardiography is helpful in differentiating amyloid patients from those with similar two dimensional echocardiographic features but without amyloidosis. Abnormally low tissue Doppler diastolic velocities are present in individuals with cardiac amyloid compared with control patients.

Cardiovascular Technologist In Malaysia

Cardiovascular Technologist In Malaysia

Background

The role of the cardiovascular technologist is increasingly complex and demanding. Not only must the cardiovascular technologist be familiar with approved clinical protocols for each type of cardiovascular examination he or she performs, the technologist also must be able to analyze the patient’s clinical history fully, in order to identify the purpose of the examination, frame the clinical question(s) that the examination is intended to answer, and expand the examination as necessary to answer the clinical question(s).

Cardiovascular technologist also plays an integral role in the treatment process, applying independent judgment, problem-solving skills, and the ability to obtain and integrate accurate diagnostic information whilst supporting the clinicians in performing the treatment. Therefore a guideline for credentialing of the practicing CVT is important to ensure appropriate standards and patient safety is upheld at all times.

The well-informed public nowadays has to be assured that the quality of the services provided by healthcare practitioner including Cardiovascular Technologists do have a minimum knowledge and competency in these specialty areas.

Description of profession

Cardiovascular technology is an allied health profession specifically focuses in diagnosis and treatment of patients with cardiac and vascular diseases. Through the use the specific high-technology equipment and at the direction of a qualified physician, performs cardiovascular examination and therapeutic procedures to create an easily definable data from which correct anatomic and physiologic diagnosis may be developed for each individual patient. The cardiovascular technologist therefore is highly specialized diagnostician of the various presentations of cardiovascular disease.

The cardiovascular technologist is also trained in advance live support technique as he or she deals with patients with high risk of cardiopulmonary arrest.

Cardiovascular Technology Sub Specialty Areas

The profession of cardiovascular technology encompasses four sub specialty arrears including:-

1)   Non-Invasive cardiovascular

2)   Invasive cardiovascular

3)   Non-invasive vascular

4)   Cardiac pacing and electrophysiology

Job Scope

The scope of job of cardiovascular technology is divided into four sub specialty areas, the jobs are including but not limited to:-

1)   Non invasive cardiovascular laboratory

1.1         Electrocardiography (EKG)

1.2         Stress Test

1.3         Ambulatory ECG monitoring

1.3.1   Holter

1.3.2   King of Heart

1.3.3   Rhythm Card

1.4         Ambulatory BP monitoring

1.5         VO2 Max and Exercise Capacity

1.6         Nuclear Medicine

1.7         Echocardiogram

1.8         Stress Echocardiogram

1.9         Transesophageal Echocardiogram (TEE)

1.10   Cardiopulmonary resuscitation

2)   Invasive Cardiovascular Laboratory.

2.1           Haemodynamic & vital signs  monitoring

2.2           Blood gas analysis and Intracardiac shunt study

2.3           Transesophageal and Transthoracic Echocardiogram

2.4           Intravascular Ultrasound (IVUS)

2.5           Intra Aortic Balloon Pump (IABP)

2.6           Rotational Atherectomy

2.7           Vascular access removal & Groin management

2.8           Diagnostic Cardiac Catheterisation Procedures

2.9           Transcatheter Cardiacvascular Intervention 

2.10     Cardiopulmonary resuscitation

         

3)   Non invasive Peripheral Vascular Laboratory.

3.1           Ankle- Brachial Index (ABI) Procedure

3.2           Carotid Ultrasound Duplex

3.3           Peripheral Artery Ultrasound Duplex

3.4           Peripheral Vein Ultrasound  Duplex

3.5           Thermography and Plethysmography Procedures

3.6           Cardiopulmonary resuscitation

4) Cardiac Pacing & Electrophysiology

4.1 Cardiac Pacing

4.1.1 Permanent Pacemaker Implantation Support

4.1.2 Permanent Pacemaker Clinic Follow-up

4.1.3 Implantable Cardiac Defibrillator (ICD)          Implantation Support

4.1.4 Implantable Cardiac Defibrillator (ICD) Clinic      Follow-up

4.1.5   Biventricular Pacemaker Implantation Support

4.1.6   Biventricular Pacemaker Clinic follow-up

4.1.7   Temporary Pacemaker Implantation Support and programming

4.2 Electrophysiology

4.2.1 Electrophysiology Study Support

4.2.2 Radiofrequency Ablation Support

             

The Sonographer Attachment Programme At USA Report : Conclusion

Conclusion

Competency in the performance of cardiovascular ultrasound examinations requires maintenance of skills in each area of practice. Each sonographer should meet the applicable procedure volume requirements and continuing medical education requirements set forth in the ICAEL standards. As of April, 2002, the ICAEL procedure volume standards require the performance of 300 resting transthoracic echocardiograms per year and 100 stress echocardiograms per year.

Sonographers must fulfill such continuing medical education requirements as may be required by the applicable credentialing organization. Those sonographers who provide services in accredited laboratories also should meet any applicable ICAEL continuing medical education requirements.

Sonographers must adhere to the scope of practice for diagnostic ultrasound professionals, and the code of ethics and must in peer review and quality assurance activities as required by the institution that operates the laboratory and by ICAEL standards if applicable.

Three-dimensional echocardiography is a safe, noninvasive imaging modality that is complementary and supplementary to 2D imaging and can be used to assess cardiovascular function and anatomy in various clinical settings. At present, available evidence suggests that 3D echocardiography provides improved accuracy and reproducibility over 2D methods for LV volume and function calculation and the derivation of mitral valve area in patients with mitral stenosis. Further technological improvements and additional clinical studies will broaden the list of appropriate applications for this exciting new ultrasound modality.

The ASE supports and encourages an expanded role of the credentialed cardiac sonographer in the selection of patients and the administration of contrast agents for echocardiography. Such responsibilities require a thorough understanding of micro bubble characteristics and interaction with cardiac ultrasound and the indications (and contraindications) for contrast agent injections. The cardiac sonographer must comply with established policies and procedures, as outlined in specific written protocols developed by the echocardiography laboratory director. When responsible for obtaining IV access, this person must have appropriate training with certification. The injection or infusion of agents ideally should be done by a physician or registered nurse following proper techniques. The use of contrast agents should be reserved for accredited or, at least, Level II echocardiography laboratories in which direct physician supervision and registered nurse support are available.

Echocardiography plays an exciting and evolving role in the care of  patient with CRT, from quantifying improvements in ventricular function and MR to optimizing the device after implantation. Although a great deal of work has been done to quantify mechanical dyssynchrony in hopes of refining patient selection and guiding lead placement, this is a complex and challenging field with future work needed and several promising studies ongoing. Technologic improvements in echocardiographic data acquisition and analysis as well as advances in our understanding of the pathophysiology of dyssynchrony and CRT have great potential to impact future clinical practice and improve patient outcome. The Dyssynchrony Writing Group is indebted to Ashley Prather and the American Society of Echocardiography staff for administrative and organizational assistance.