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How to interpret an echocardiography report (for Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from the non-imager)? Manish Bansal,1 Partho P Sengupta2,3

1Department of , Introduction Learning objectives Medanta – The Medicity, Echocardiography is the most widely used cardiac Gurgaon, India 2 imaging modality. Its ability to permit compre- Division of Cardiology, Heart ► To be able to interpret findings from an hensive assessment of cardiac structure and func- ► and Vascular Institute, West echocardiographic study in a systematic Virgina University, Morgantown, tion combined with its safety, wide availability and manner. WV, USA ease of application render it indispensable in the 3 ► To be able to appreciate relative clinical value of West Virginia University management of most patients with a suspected or ► various echocardiographic findings in different known cardiac illness. It is therefore not surprising Correspondence to clinical scenarios and recognise those directly that the use of echocardiography, when performed Dr Partho P Sengupta, Heart impacting clinical decision making. and Vascular Institute, West for appropriate clinical indications, has been shown ►► To be able to integrate echocardiographic Virginia University, 1 Medical to be associated with decreased odds of in-hospital findings with those of clinical examination and Center Drive Morgantown, WV mortality.1 other investigations. 26506, USA; Partho.​ ​Sengupta@​ However, the wide applicability of echocar- wvumedicine.org​ ►► To be able to integrate echocardiography in the diography has resulted in an increasing number overall patient care. Published Online First of non-cardiologists and non-imagers being 7 September 2017 involved in its use for clinical purposes. Since many of them are not well familiar with the echo- To maximally benefit from echocardiography, it cardiography findings, they often find it difficult is important that the ordering physicians clearly to navigate through and interpret an echocardi- specify the indication for performing the test to ography report. Moreover, echocardiography is enable the echocardiographer extract relevant a dynamic field with constant addition of newer information from the test. At the same time, the imaging modalities (eg, three-dimensional (3D) echocardiographers reporting the study should echocardiography), newer measurements (eg, also ensure that all the relevant details are provided strain) or changes in interpretation algorithms in the echocardiography report. They should also (eg, recent revision of the left ventricular (LV) provide an overall interpretation of the echo- 2 diastolic function assessment guidelines ). The cardiographic findings, instead of just reporting

reporting format, terminologies used and the the individual findings. If the echocardiography http://heart.bmj.com/ technologies available at disposal also vary across report does not adequately answer the clinical echocardiography laboratories, further adding question or if there is a discrepancy between the to the complexity of the whole process. This clinical assessment and the echocardiographic review therefore describes a systematic approach findings, it is desirable that the treating physician to help enable non-imagers extract clinically reaches out to the echocardiographer directly and relevant information from an echocardiography discusses the implications of various echocardio- report and effectively apply it for clinical deci- graphic findings and the need for either a repeat sion making in their patients. echocardiogram or an alternate diagnostic testing. on 17 October 2018 by guest. Protected copyright.

Specific echocardiographic findings Interpreting an echocardiography When interpreting an echocardiography report, report the attention should first be given to the clinical Echocardiography tends to generate a large indication for which the study was performed, the amount of structural and functional data, but nature of the study performed (ie, transthoracic not all the information contained within an or transesophageal, focused or complete), haemo- echocardiography report has similar impact dynamics at the time of the study and the echo- on clinical outcomes. Therefore, the primary cardiographer’s impression of the image quality. goal for the treating physicians is to promptly Acoustic image quality is a major determinant of recognise those echocardiography findings the diagnostic accuracy of transthoracic echocar- that directly impact clinical decision making. diography (TTE) and when image quality is poor, Tables 1 and 23summarise key echocardiography all echocardiographic findings need to be viewed findings that maximally impact clinical deci- with caution. The use of ultrasound contrast or sion making, whereas table 3 outlines an approach performance of transoesophageal echocardiog- to reach the aetiological diagnosis in various raphy (TOE) help overcome these challenges in clinical presentations. Additionally, a suggested the majority of the cases, but alternate imaging T Bansal M,o cite: approach for further diagnostic evaluation based modalities such as nuclear scan, computed tomog- Sengupta PP. Heart on different echocardiographic findings is also raphy (CT) or magnetic resonance imaging (MRI) 2017;103:1733–1744. provided in figure 1. may be needed in difficult cases.

Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 1733 Education in Heart

table 1 Key echocardiographic findings that impact clinical decision making in various common cardiac conditions Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from Clinical condition Echocardiographic findings Therapeutic implications LVEF LVEF influences almost every therapeutic decision in these patients Distribution and severity of RWMA Need for and the choice of coronary intervention Presence and severity of secondary mitral regurgitation Choice of coronary intervention; need for concomitant surgery during coronary artery bypass surgery PASP Optimisation of medical management; need for advanced therapies such as mechanical circulatory support Non-ischaemic dilated LVEF Medical management; need for ICD and CRT; advanced heart failure therapies Presence and severity of secondary mitral regurgitation Medical management; need for MR intervention (eg, mitra-clip) PASP Optimisation of medical management; need for advanced heart failure therapies Mitral regurgitation Severity of mitral regurgitation Need for mitral valve surgery Valve morphology Timing and the nature of mitral valve surgery LV dimensions and EF Timing and the nature of mitral valve surgery PASP Need for mitral valve surgery Other valve lesions Timing and the nature of mitral valve surgery Mitral stenosis Severity of mitral stenosis (valve area, gradients) Timing and the choice of mitral valve intervention Valve morphology, subvalvular apparatus Timing and the choice of mitral valve intervention Concomitant mitral regurgitation, other valve lesions Timing and the choice of mitral valve intervention PASP Need for mitral valve intervention LA/LA appendage clot Choice of mitral valve intervention Severity of aortic stenosis (valve area, gradients) Need for and the timing of intervention LVEF Need for and the timing of aortic valve intervention Other valve lesions Need for and the timing of aortic valve intervention Aortic root/ascending dimensions Need for concomitant aortic root replacement during aortic valve surgery Aortic regurgitation Severity of aortic regurgitation Need for aortic valve surgery Valve morphology Need for and the type of aortic valve surgery LV dimensions and EF Timing of aortic valve surgery Aortic root/ascending aorta dimensions Need for concomitant aortic root replacement during aortic valve surgery Other valve lesions Need for and the timing of aortic valve intervention http://heart.bmj.com/ Infective Size, location and mobility of the vegetations Need for surgical management for endocarditis Nature of the underlying valve lesion, severity of valve Need for and the timing of surgical management dysfunction Intracardiac abscess, other complications of infective Need for and the timing of surgical management endocarditis Hypertrophic cardiomyopathy Location and severity of LV hypertrophy Need for surgical myomectomy or Need for ICD

Systolic anterior motion of mitral apparatus and LV outflow Need for surgical myomectomy or alcohol septal ablation on 17 October 2018 by guest. Protected copyright. tract obstruction Need for mitral valve surgery Severity of mitral regurgitation Need for mitral valve surgery Restrictive cardiomyopathy Any echocardiographic features suggestive of the underlying Steroids, antithrombotics and haematological therapy in aetiology (eg, LV/RV apical obliteration in endomyocardial hypereosinophilic syndrome fibrosis or hypereosinophillic syndrome; significant LV Evaluation and management of underlying plasma cell dyscrasia in hypertrophy with altered myocardial echotexture, thickened amyloid interatrial septum and so on in ) Mainly supportive treatment in most other cases PASP Optimisation of medical management; need for advanced heart failure therapies Left and right heart filling pressures Optimisation of medical management; need for advanced heart failure therapies Location and size of effusion Need for and the modality for Haemodynamic features of tamponade (RA/RV diastolic Need for pericardiocentesis collapse, respiratory variation in mitral and tricuspid inflow velocities, dilated and non-collapsing inferior vena cava) Any echocardiographic features of underlying constriction Evaluation and management of constrictive pericarditis if evolves (pericardial thickening, septal bounce and so on) later on Ventricular tachyarrhythmia LVEF, any RWMA Need for coronary intervention; ICD RV size, systolic function and aneurysms Need for ICD Suspected cardioembolic Any LA/LA appendage clot Need for anticoagulation Continued 1734 Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 Education in Heart

Table 1 Continued Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from Clinical condition Echocardiographic findings Therapeutic implications Any LV clot Need for anticoagulation, surgical removal of clot Any other intracardiac mass (location, size, nature) Need for surgery; treatment of underlying condition Patent foramen ovale/ Closure of patent foramen ovale/atrial septal defect CRT, cardiac resynchronisation therapy; EF, ; ICD, implantable cardioverter defibrillator; LA, left atrial; LV, left ventricular; LVEF, left ventricular ejection fraction; PASP, systolic pressure; RA, right atrial; RV, right ventricular; RWMA, regional wall motion abnormality.

LV systolic function STE and strain measurement are provided else- LV systolic function, traditionally measured as where11 12 but suffice is to mention that of all the LV ejection fraction (LVEF), is a key information available strain measurements, global longitudinal sought from echocardiography. LVEF is pivotal strain (GLS) is the most robust and reproducible in the management of all patients with cardiac enough for routine clinical use.6 GLS is more repro- dysfunction, regardless of whether such dysfunction ducible than even LVEF. The normal value of GLS is due to a primary cardiac disease or is secondary varies with the equipment and the software used to a systemic illness. Management of fluids and for obtaining and analysing the images, but a value inotropic support, decisions regarding myocardial more negative than −16% to 18% is generally revascularisation,4 timing and the choice of valve considered to be normal. interventions,3 need for cardiac resynchronisation The main clinical application of GLS is in the therapy (CRT) and/ or an implantable cardioverter recognition of subclinical LV systolic dysfunction, defibrillator (ICD)5 are some of the decisions that which is common during the early stages of several are largely dependent on LV systolic function and cardiac and non-cardiac disorders such as treatment thus LVEF. Additionally, the recognition of impaired with potentially cardiotoxic cancer chemothera- LV systolic function in patients presenting with pies,13 valvular heart diseases,14 ,15 dyspnoea, haemodynamic compromise, stroke, heart failure with preserved LVEF,15 16 hyperten- and so on, helps in triaging them into appropriate sion,17 obesity18 and so on. Reduced GLS in these management pathways. conditions indicates worse prognosis. However, While there are several methods for estimation the therapeutic implications of such a finding are of LVEF by echocardiography, modified biplane not yet well established as studies linking strain- Simpson’s method is the recommended method.6 guided management with improvement in clin- However, in real-life practice, LVEF is often ical outcomes are currently lacking. Nevertheless, assessed visually by eyeballing, which has been in some clinical conditions, such as in patients shown to have high degree of accuracy in case of receiving potentially cardiotoxic cancer chemother- experienced readers.7 8 When available, 3D echo- apies, GLS is now being increasingly used for thera- 13 cardiography provides a more accurate assessment peutic decision making as well. http://heart.bmj.com/ of LVEF and LV volumes.9 Two important points need to be considered Regional versus global LV systolic dysfunction when interpreting LVEF report. First, echocardi- In patients with reduced LVEF, the distinction ography has certain degree of inherent measure- between global and regional LV systolic dysfunc- ment variability. Although in most patients, this tion has major clinical implications. Global LV measurement variability has little practical signifi- hypokinesia without any significant regional vari- cance, it becomes relevant when LVEF value is near ation generally indicates non-ischaemic aetiology, on 17 October 2018 by guest. Protected copyright. the threshold for defining the need for a specific whereas regional wall motion abnormalities are cardiac intervention (e.g. LVEF ≈50% in patients considered to be the sine qua non of the underlying with aortic stenosis (AS) or aortic regurgitation coronary artery disease. However, exceptions are (AR), ≈60% in patients with mitral regurgitation not uncommon as the patients with severe isch- (MR), ≈35% in patients potentially requiring aemic LV systolic dysfunction may present with CRT). In these circumstances, one should always global hypokinesia whereas regional variations are corroborate LVEF with other echocardiographic known to occur even in the absence of coronary findings and the overall clinical picture. 3D echo- artery disease (box 1). In patients with regional cardiography, as mentioned above, provides more LV systolic dysfunction, the location of the wall accurate and reproducible measurements,9 10 but if motion abnormalities provides useful clue about the uncertainty still persists, cardiac MRI may be the culprit artery (figure 2), which has prognostic needed to confirm LV volumes and EF (figure 1). and therapeutic implications. Additionally, echocar- Second, as LVEF is a global measure of LV diographers often also comment on the segmental systolic function, it is not sensitive enough to detect myocardial thickness. A thinned-out segment subtle impairment of LV contractile function during is likely to be scarred and is unlikely to recover the early stages of the diseases. Myocardial strain regardless of the treatment.19 imaging offers a promising solution in this regard. Speckle-tracking echocardiography (STE), which is Cardiac chamber sizes a greyscale-based technique, is the current modality Cardiac chamber dimensions are routinely reported of choice for this purpose.11 Technical details of in echocardiography reports. In case of ventricles,

Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 1735 Education in Heart

Table 2 Clinically relevant threshold values for common echocardiographic measurements Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from P arameter Clinically relevant threshold values and their implications Remarks LVEF <60% Threshold for intervention in chronic severe MR3 33 Three-dimensional echocardiography <50% Indication for AVR in severe AS, severe AR3 33 more accurate than two-dimensional echocardiography; cardiac MRI may be Threshold above which heart failure is classified as ‘heart failure with needed when LVEF value is close to a preserved EF’34 clinically relevant threshold <40% Used for diagnosing ‘heart failure with reduced EF’34 <35% Indication for CRT in appropriately selected patients34 35 <30%–35% Indication for ICD implantation for primary prevention of sudden cardiac death, depending on functional class and underlying aetiology34 35 <30% Only a class IIb indication for surgery in chronic severe MR3 33 LV end-systolic dimension >50 mm (>25 mm/m2) Class IIa indication for AVR in severe AR3 33 Three-dimensional echocardiography >40 mm Class I indication for surgery in chronic severe MR3 more accurate than two-dimensional echocardiography; cardiac MRI may be >45 mm Class I indication for surgery in chronic severe MR33 3 needed when values close to a clinically LV end-diastolic dimension >65 mm Class IIb indication for AVR in severe AR relevant threshold >70 mm Class IIa indication for AVR in severe AR33 Left atrial volume >34 mL/m2 Threshold for defining as increased left atrial volume6 Mitral stenosis Mitral valve area <1.5 cm2 Indicates significant MS; is a threshold for intervention in appropriately Planimetry more accurate than pressure selected patients3 half-time method, provided image quality is good Mean gradient >10 mm Hg Indicates severe MS3 20 Dependent on , other haemodynamic variables Aortic stenosis Mean gradient >40 mm Hg Consistent with a diagnosis of severe AS; Velocity and gradient may be low despite Class I indication for AVR in symptomatic patients3 33 aortic valve area being <1.0 cm2—this is >60 mm Hg Class IIa indication for AVR in asymptomatic AS3 termed as low-gradient severe AS (refer to section on low-gradient severe AS) Peak jet velocity >4 m/s Class I indication for AVR in symptomatic patients3 >5 m/s Class IIa indication for AVR in asymptomatic AS3 >5.5 m/s Class IIa indication for AVR in asymptomatic AS33 Aortic valve area <1 cm2 Used for diagnosing severe AS; threshold for intervention in Usually derived using continuity equation, appropriately selected patients3 33 which is prone to errors Proximal aorta (aortic root/ ≥45 mm Class IIa indication for aortic root surgery for patients with Marfan’s Measurements on echocardiography (uses 33

ascending aorta) dimensions syndrome with additional risk factors leading edge-to-leading edge approach) http://heart.bmj.com/ Class IIa indication for aortic root surgery in patients undergoing AVR, approximately 2 mm larger than the same especially if with disease26 36 on CT (uses inner edge-to-inner edge ≥50 mm Class I indication for aortic root surgery in Marfan’s syndrome33 approach) Class IIa indication for aortic root surgery for patients with bicuspid valve with additional risk factors33 36 ≥55 mm Class I indication for aortic root surgery for all patients (regardless of the aortic valve morphology and severity of AR)26 36

Class IIa indication for aortic root surgery for all patients (regardless of on 17 October 2018 by guest. Protected copyright. the aortic valve morphology and severity of AR)33 Tricuspid regurgitation Peak gradient at rest >30 mm Hg Threshold for defining as abnormal >50 mm Hg Class IIa indication for MVR in chronic severe MR3 33 Tricuspid annulus size >4 cm (>21 mm/m2) Generally indicates need for concomitant tricuspid valve surgery in patients with any degree of functional TR undergoing mitral valve surgery3 33 37 38 LV diastolic function Mitral E/A ratio >2 Generally indicates restrictive mitral filling pattern with raised left atrial LV diastolic function parameters should not pressure2 be viewed in isolation and should always Mitral E/e’ (average) >14 Generally indicates raised left atrial pressure2 be corroborated with other clinical and echocardiographic findings A, mitral inflow late diastolic velocity; AR, aortic regurgitation; AS, aortic stenosis; AVR, aortic ; CRT, cardiac resynchronisation therapy;; E, mitral inflow early diastolic velocity; e’, mitral annular early diastolic velocity; EF, ejection fraction; ICD, implantable cardioverter defibrillator; LV, left ventricular; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; MS, mitral stenosis; MVR, .

the end-diastolic measurements provide an estimate In contrast, the atrial size is generally measured at of chamber enlargement, whereas the end-systolic the end of ventricular only because that is dimensions serve as a surrogate for systolic function. the time in the when the atria are at

1736 Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 Education in Heart

Table 3 Approach to interpretation of echocardiography findings in relation ot the clinical presentation* Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from Clinical presentation Likely aetiology Corroborative findings Coronary artery disease ►► Regional wall motion abnormalities (sometimes global LV systolic dysfunction) ►► Wall thinning, scarring ►► Raised PASP ►► RV dilatation/dysfunction ►► Sometimes, visible thrombus in main pulmonary artery or right-side cardiac chambers ►► Visible dissection flap ►► Dilated aortic root/ascending aorta ►► Differential flow pattern in aorta ►► Sometimes AR, pericardial effusion ►► Aortic valve may be bicuspid Pericarditis ►► Variable extent of pericardial effusion and/or pericardial thickening ►► Haemodynamic features of constriction in case of effuso-constrictive pericarditis Dyspnoea LV systolic dysfunction ►► Reduced myocardial contractile function, regional or global ►► Wall thinning, scarring ►► Evidence of raised LV filling pressure ►► Secondary MR Heart failure with preserved ejection fraction ►► LV hypertrophy of variable extent ►► Usually small size LV cavity ►► Normal or near normal LV ejection fraction, GLS often reduced ►► Significant VL diastolic dysfunction with raised LV filling pressures, PASP Significant aortic or mitral valve disease ►► Structural abnormality of the valve ►► Doppler evidence of significant alvev dysfunction (MS, MR, AS or AR) ►► Cardiac chamber enlargement depending on the valve lesion Hypertrophic cardiomyopathy ►► Significant VL hypertrophy, often asymmetrical ►► Altered myocardial echotexture ►► Systolic anterior motion of mitral valve apparatus with variable severity of MR ►► LV outflow tract obstruction ►► LV diastolic dysfunction Restrictive cardiomyopathy ►► Normal-sized ventricles, with or without hypertrophy ►► Usually normal LV ejection fraction, GLS almost invariably reduced ►► Doppler evidence of raised intracardiac filling pressures, elevated PASP ►► Specific abnormalities in certain diseases (eg, LV/RV apical obliteration in endomyocardial fibrosis or hypereosinophillic syndrome; significant LV hypertrophy with altered myocardial echotexture, thickened interatrial septum, and so on, in amyloidosis) http://heart.bmj.com/ Pulmonary ►► Raised PASP ►► RV hypertrophy, dilatation and dysfunction ►► Dilatation of the pulmonary artery Fever ►► Vegetations, location depending on the predisposing factors (TOE may be needed) ►► ntracardiac abscess ►► Structural and functional abnormality of the valves Pericarditis ►► Variable extent of pericardial effusion and/or pericardial thickening on 17 October 2018 by guest. Protected copyright. ►► Haemodynamic features of constriction in case of effuso-constrictive pericarditis Stroke Intracardiac thrombi ►► Visible intracardiac thrombus may or may not be present. TOE required to rule out LA/LA appendage thrombus ►► Evidence of predisposing condition—LV systolic dysfunction/ aneurysm, mitral valve obstruction, and so on, but may be completely normal if AF is the only issue Intracardiac tumour ►► Visible intracardiac mass, usually on the left side Paradoxical embolism ►► Atrial septal defect or patent foramen ovale (agitated saline injection often required) ►► Evidence of persistent or intermittent right to left shunt (Valsalva manoeuvre often required) Vegetation ►► Visible vegetation in the left-side cardiac chambers (right-sided endocarditis may also cause stroke in presence of interatrial communication) ►► May be infective or non-infective Mitral annular calcification ►► Visible mitral annular calcification with or without mobile components ►► Variable degree of mitral valve dysfunction Swelling of feet ►► Raised PASP ►► RV hypertrophy, dilatation and dysfunction ►► Dilated inferior vena cava ►► Evidence of left-side cardiac pathology if that is the primary disease Continued

Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 1737 Education in Heart

Table 3 Continued Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from Clinical presentation Likely aetiology Corroborative findings Primary RV systolic dysfunction ►► RV dilatation and systolic dysfunction ►► Dilated inferior vena cava ►► Usually normal pulmonary pressures Primary tricuspid valve disease ►► Structural abnormality of tricuspid valve ►► Doppler evidence of significant tricuspid stenosis or regurgitation ►► RA/RV dilatation with or without RV systolic dysfunction ►► Dilated inferior vena cava Restrictive cardiomyopathy ►► Findings as described above Constrictive pericarditis ►► Thickened , may be calcified ►► Evidence of exaggerated ventricular interdependence (septal bounce, significant respiratory variation in mitral and tricuspid inflow velocities) ►► Preserved mitral annular velocities despite raised LV filling pressure (annulus paradoxus) ►► Dilated inferior vena cava Haemodynamic collapse Several possibilities such as sudden severe LV systolic ►► Echocardiographic features will vary according to the aetiology (as discussed dysfunction, RV infarction, mechanical complication of MI, above) infective endocarditis with acute valve dysfunction, prosthetic valve thrombosis, pericardial effusion with tamponade, massive pulmonary embolism, and so on. *This table describes commonly encountered aetiologies and clinical presentations and is not exhaustive. In addition, exceptions may occur, and therefore clinical judgement is warranted in each individual case. AF, ; AR, aortic regurgitation; AS, aortic stenosis; GLS, global longitudinal strain; LA, left atrial; LV, left ventricular; MI, ; MR, mitral regurgitation; MS, mitral stenosis; PASP, pulmonary artery systolic pressure; RV, right ventricular; TOE, transoesophageal echocardiography.

their largest sizes. For accurate interpretation, all Cardiac chamber dimensions provide useful the chamber size measurements should preferably supportive evidence for the severity of other be indexed to body surface area and compared with cardiac lesions. Thus, significant LV enlargement the predefined age-specific, gender-specific and in a patient with chronic MR or AR indicates that ethnic-specific normal ranges.6 the valve lesion is severe, unless there is some other http://heart.bmj.com/ on 17 October 2018 by guest. Protected copyright.

Figure 1 Approach to referral for further diagnostic evaluation based on common echocardiographic findings. AR, aortic regurgitation; AS, aortic stenosis; echo, echocardiography; LV, left ventricular; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; MS, mitral stenosis; RWMA, regional wall motion abnormality; TOE, transoesophageal echocardiography; TTE, transthoracic echocardiography.

1738 Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 Education in Heart

The severity of valvular dysfunction is assessed on Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from Box 1 non-coronary causes of regional left ventricular systolic the basis of a combination of 2D and Doppler-de- dysfunction rived parameters.20–22 For stenotic lesions, valve area and transvalvular gradients are the key param- Conditions eters (table 4)20 and both should be considered ►► Non-ischaemic (disproportionate hypokinesia of together for accurate interpretation. The severity inferior wall and interventricular septum is common) of regurgitant lesions is based on a combination of ►► Stress cardiomyopathy or Takatsubo cardiomyopathy qualitative and quantitative parameters including ►► Abnormal electrical conduction jet size (planimetered jet area, jet width or vena –– Conduction system abnormalities such as left contracta, as appropriate), effective regurgitant –– Ventricular pacing orifice area, regurgitant volume and fraction and –– Ventricular ectopics the impact of regurgitation on upstream and down- –– Ventricular pre-excitation stream cardiac chambers (table 5).21 22 ►► Postpericardiotomy state Caution needs to be exercised when interpreting ►► Pericardial constriction Doppler-based measurements as they are influenced ►► Right ventricular pressure and by haemodynamics and can lead to erroneous inter- ►► Systemic diseases such as sarcoidosis, haemochromatosis and so on pretation if viewed in isolation. Valve gradients are ►► Normal variants typically exaggerated in presence of tachycardia –– Early relaxation and increased state, whereas regur- –– Tardokinesis gitant lesions are suppressed when systolic blood ►► External compression pressure is reduced. Table 6 summarises common conditions that affect echocardiographic assessment of valve lesion severity. Apart from these consider- cause for LV enlargement. Similarly, the enlarge- ations, careful evaluation of the valve morphology ment of right and right in a patient is also very helpful in determining the severity of the with apparently normal left-side structures raises valve dysfunction. For example, in a patient with the possibility of a haemodynamically significant increased LV outflow gradient, normally opening atrial septal defect. Apart from these diagnostic aortic valve leaflets would exclude valvular AS as considerations, chamber dimensions have thera- the cause of increased gradients and would warrant peutic implications also, as summarised in tables 1 search for an alternate explanation for the same (eg, and 2. subvalvular obstruction, high cardiac output state and so on). Conversely, a markedly thickened and Valve lesions calcific aortic valve with reduced opening strongly Valve lesions constitute the second most common suggests the possibility of significant AS, even if the indication for echocardiography, after assessment transvalvular gradient is not particularly high. Simi-

of LV systolic function. Echocardiography provides larly, the presence of a ruptured chordae with flail http://heart.bmj.com/ comprehensive information about the valve struc- mitral valve leaflet strongly suggests the possibility ture and function and is pivotal in the management of severe MR even if the colour flow Doppler is not of valve diseases. TOE often provides incremental much impressive. information and is frequently required for the eval- When a significant valve lesion is reported, the uation of valve lesions, esp. the mitral valve lesions treating physician should then look for other echo- (figure 1). cardiographic characteristics that determine the need for, the timing of,and the nature of the valvular intervention. These include valve morphology, LV on 17 October 2018 by guest. Protected copyright. systolic function, intracardiac haemodynamics, coexisting valvular and non-valvular pathologies and so on. Balloon mitral valvotomy in rheumatic mitral stenosis, or replacement in MR, concomitant aortic root replacement in a patient with aortic valve disease and so on are some of the decisions that are significantly influenced by the valve morphology.3 Low gradient severe AS is a unique entity that often poses diagnostic dilemma and merits specific mention. Traditionally, severe AS is diagnosed when aortic valve area is <1 cm2 and the mean transval- vular gradient is >40 mm Hg (or peak velocity >4 m/s). However, a sizeable proportion of the patients with aortic valve area <1 cm2 present with trans- valvular gradients much below the threshold for Figure 2 Typical left ventricular myocardial distribution of coronary arterial supply. severity. This is often because of reduced stroke Reproduced from: Lang RM, Bierig M, Devereux RB, et al. J Am Soc Echocardiogr. volume (<35 mL/m2) and may occur even when the 2005;18:1440–1463. LAD, left anterior descending; LCx, left circumflex; RCA, right LVEF is preserved. This entity is common in elderly coronary artery. hypertensive individuals with small LV cavity size.

Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 1739 Education in Heart

limitations, many echocardiography labs have Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from Table 4 Echocardiographic criteria for grading severity of mitral and aortic stenosis20 now resorted to reporting only peak TR velocity P arameter Mild Moderate Severe without mentioning PASP. Regardless of these tech- Mitral stenosis nical issues, estimated PASP (or TR jet velocity) Specific findings has proved to be a useful measure of intracardiac Mitral valve area (cm2) >1.5 1.0–1.5† <1.0† haemodynamic status. In patients with right-sided Supportive findings lesions, PASP helps in distinguishing between Mitral valve mean gradient (mm Hg)* <5 5–10 >10 primary versus secondary right heart failure, Pulmonary artery systolic pressure (mm Hg) <30 30–50 >50 whereas in cases of left-sided cardiac lesions such Aortic stenosis as LV systolic dysfunction, aortic and mitral valve diseases, cardiomyopathies and so on, PASP serves Aortic jet peak velocity (m/s) 2.6–2.9 3.0–4.0 >4.0 as a measure of the overall haemodynamic burden Aortic valve mean gradient (mm Hg) <20 20–40 >40 imposed by these lesions and therefore has prog- Aortic valve area (cm2) >1.5 1.0–1.5 <1.0 2 2 nostic and therapeutic implications. For example, Indexed aortic valve area (cm /m ) >0.85 0.60–0.85 <0.60 an elevated PASP, either at rest or during exercise, is Velocity ratio >0.50 0.25–0.50 <0.25 in itself an indication for mitral valve intervention *At heart rates between 60 beats/min and 80 beats/min and in sinus rhythm. in a patient with significant mitral stenosis or MR.3 †The 2014 American college of Cardiology/American Heart Association guideline for the management Estimation of RV filling pressure or mean RA of patients with (J Am Coll Cardiol. 2014;63:e57-185) considers mitral valve area <1.5 cm2 as severe mitral stenosis. When mitral valve area is >1.5 cm2, it is termed as progressive pressure is performed by evaluating inferior vena 25 mitral stenosis. cava (IVC) size and collapsibility. The status of the IVC helps in guiding fluid management in critically ill patients. Additionally, dilated IVC is also helpful in diagnosis of certain cardiac disorders such as Recognition of this entity is clinically important restrictive cardiomyopathy (RCM) or constrictive as the long-term prognosis of these patients is not 23 24 pericarditis. However, the IVC size and collaps- necessarily benign. Such patients will require ibility are not reliable indicators of RA pressure more comprehensive evaluation and should be in mechanically ventilated patients. Interrogation referred to a valve specialist. of hepatic vein flow pattern can be of help in such Intracardiac haemodynamics situations.25 Pulmonary artery systolic pressure (PASP) has been Echocardiography also permits assessment of LV one of the most popular haemodynamic parameters diastolic function and estimation of LV filling pres- derived from echocardiography. It is estimated from sure. The American Society of Echocardiography tricuspid regurgitation (TR) jet, using the modified has recommended a simplified integrative algo- Bernoulli’s principle. Since this method has some rithm for this purpose (figure 3). From a clinical http://heart.bmj.com/ Table 5 Echocardiographic criteria for diagnosing chronic severe mitral and aortic regurgitation21 22 P arameters Chronic severe primary mitral regurgitation Chronic severe aortic regurgitation Structural parameters Left atrial size Usually dilated – Left ventricular size Usually dilated Usually dilated Valve apparatus Abnormal Abnormal

Doppler parameters on 17 October 2018 by guest. Protected copyright. Colour flow jet area (cm2)* Large central jet (usually >10 cm2, or >40% of left atrial – area) or variable size wall hugging jet in left atrium Colour flow jet width in LVOT* – Large in central jets; variable in eccentric jets Jet deceleration rate- continuous wave (Pressure half-time, ms)† – Steep <200 Diastolic flow reversal in descending aorta—pulsed wave – Prominent holodiastolic reversal (end-diastolic velocity >20 cm/s) Mitral inflow (pulsed wave) E wave dominant (E usually >1.2 m/s) – Jet density (continuous wave) Dense Dense Jet contour (continuous wave) Early peaking triangular – Pulmonary vein flow Systolic flow reversalc – Quantitative parameters Vena contracta width (cm)* >0.7 ≥0.6 Jet width/LVOT width, %* – ≥65 Jet CSA/LVOT CSA, %* – ≥60 Regurgitant volume (mL/beat) ≥60 ≥60 Regurgitant fraction (%) ≥50 ≥50 Effective regurgitant orifice area (cm2) ≥0.40 ≥0.30 CSA, cross sectional area; LVOT, left ventricular outflow tract. *At a Nyquist limit of 50–60 cm/s. †Pressure half-time is shortened with increasing left ventricular diastolic pressure and vasodilator therapy.‡Pulmonary venous systolic flow reversal is specific but not sensitive for severe mitral regurgitation.

1740 Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 Education in Heart

Table 6 Common conditions resulting in overestimation or underestimation of the severity of valve lesions (other than technical errors) Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from Factors leading to underestimation of severity Factors leading to overestimation of severity Mitral stenosis Underestimated by gradients Overestimated by gradients ►► Bradycardia ►► Tachycardia ►► Severe tricuspid regurgitation ►► Significant mitral regurgitation ►► Severe tricuspid stenosis ►► High cardiac output states, for example, anaemia ►► CHF Overestimated by pressure half-time method Underestimated by pressure half-time method ►► Impaired LV relaxation (elderly age, hypertension, aortic stenosis and ►► Low left atrial compliance so on) ►► Severe aortic regurgitation ►► LVH due to hypertension, aortic stenosis—variable effect due to competing influence of raised LV filling pressure and LV relaxation impairment Underestimated by planimetry ►► Subvalvular obstruction ►► CHF with reduced valve opening Mitral regurgitation ►► Low systemic ►► High blood pressure ►► Low systemic ►► Concomitant severe aortic stenosis ►► Volume depletion Aortic stenosis Underestimated by valve gradients Overestimated by valve gradients ►► LV systolic dysfunction ►► Coexisting aortic regurgitation ►► Reduced LV due to small LV cavity size ►► High cardiac output states, for example, anaemia ►► Increased systemic vascular resistance, increased valvulo-arterial ►► Post-PVC assessment impedance ►► Coexisting subaortic stenosis (fixed or dynamic) ►► Uncontrolled hypertension Overestimated by planimetry ►► Severe mitral stenosis or mitral regurgitation ►► LV systolic dysfunction (pseudosevere stenosis) Aortic regurgitation ►► Low systemic blood pressure ►► High blood pressure ►► Low systemic vascular resistance ►► Increased systemic vascular resistance ►► Tachycardia ►► LV systolic dysfunction ►► Severe aortic stenosis (reduced LV compliance) CHF, congestive heart failure; LV, left ventricular; LVH, left ; PVC, premature ventricular contraction.

standpoint, however, the presence of restrictive mitral inflow pattern signifying advanced LV diastolic dysfunction is the most useful. A restrictive

filling pattern in patients with LV systolic dysfunc- http://heart.bmj.com/ tion is a poor prognostic marker and calls for more aggressive decongestion and further optimisation of heart failure therapies. When observed in patients with preserved LV systolic function, a restrictive LV filling pattern has considerable diagnostic value as it allows diagnosis of heart failure with preserved EF, RCM or constrictive pericarditis. on 17 October 2018 by guest. Protected copyright.

Aortic diseases Aortic dissection is one of the true cardiac emergen- cies and needs to be promptly diagnosed and treated surgically, especially when it involves the proximal segment of aorta. TTE is the initial modality used for diagnosing aortic dissection and has a sensi- tivity of 77%–80% for this purpose. TOE has much higher (≈98%) sensitivity for diagnosing ascending aortic dissection and should always be employed when the index of suspicion is high and the TTE is non-confirmatory.26 27 Once ascending aortic Figure 3 Algorithm for echocardiographic estimation of left atrial pressure and dissection is diagnosed, the impact of dissection on grading left ventricular diastolic function in patients with myocardial disease. Modified the aortic valve function, involvement of coronary from: Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation ostia and the presence of pericardial effusion need of left ventricular diastolic function by echocardiography: An update from the American to be confirmed to help determine the appropriate Society of Echocardiography and the European Association of Cardiovascular Imaging. J management strategy. Am Soc Echocardiogr. 2016;29:277–314. A, mitral inflow late diastolic velocity; E, mitral Aortic root enlargement may occur either in inflow early diastolic velocity; e’, mitral annular early diastolic velocity; LA, left atrial; combination with an aortic valve disease or as an LAP, left atrial pressure; TR, tricuspid regurgitation. isolated entity. In such patients, accurate assessment

Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 1741 Education in Heart

is difficult and is associated with a greater risk Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from Key messages of complications when pericardial effusion is small or when it is confined posterior to the left ►► Echocardiography has the capability to provide a large amount of cardiac ventricle. structural and functional information. However, the clinical utility of In patients with suspected constrictive pericar- echocardiography is dependent on the ability of the treating physician to ditis, pericardial thickening and calcification may extract relevant information from the echocardiography report. be difficult to discern on echocardiography, and it ►► For a non-imager, the primary goal should be to recognise those is usually the haemodynamic features that lead to echocardiography findings that directly impact clinical decision making. the diagnosis. The haemodynamic features sugges- ►► All echocardiographic findings should be viewed in relation to the overall tive of constriction include evidence of exagger- clinical scenario. When diagnostic uncertainty persists, further evaluation ated ventricular interdependence (interventricular using transoesophageal echocardiography, cardiac CT, MRI, nuclear imaging septal bounce, shift in septal position with respi- and so on may be needed. ration, significant respiratory variation in mitral ►► Left ventricular ejection fraction (LVEF), despite its limitations, remains and tricuspid inflow velocities), preserved mitral the most important determinant of cardiac outcomes in a wide variety of annular early diastolic velocity despite evidence clinical conditions and is one of the most important findings sought from the of elevated filling pressure and dilated non-col- echocardiography report. lapsing IVC.29 Since RCM also presents with ►► Speckle tracking echocardiography-based global longitudinal strain normal-sized ventricles with elevated filling measurement can help in recognising subclinical left ventricular (LV) systolic pressures, there is always a diagnostic dilemma dysfunction during the early stages of the diseases when LVEF is still within between these two conditions. Unlike constric- the normal range. While it has therapeutic implications in patients receiving tive pericarditis, RCM is characterised by marked potentially cardiotoxic chemotherapy, its role in decision making in other impairment of mitral annular velocities and the conditions is not yet well established. lack of the features suggestive of exaggerated ►► In patients with significant valve lesions, it is important to look for ventricular interdependence.29 In addition, strain additional echocardiographic characteristics that help in planning imaging can also be helpful in making this distinc- management strategy. These include valve morphology (ie, aetiology of tion. The finding of preserved longitudinal strain valve dysfunction and suitability for repair), LV systolic function, intracardiac favours a diagnosis of constrictive pericarditis, but haemodynamics, coexisting valvular and non-valvular pathologies and so on. converse is not true as reduced longitudinal strain ►► Presence of significant LV diastolic dysfunction (especially restrictive may occur in both these conditions.30 pattern) is a bad prognostic marker. In patients with LV systolic dysfunction, it indicates the need for more aggressive decongestion and further optimisation of heart failure therapies, whereas in patients with preserved Other abnormalities LV systolic function, it has considerable diagnostic value (diagnosis of heart During echocardiography, numerous other findings failure with preserved EF, restrictive cardiomyopathy and so on). are encountered, which may be coincidental or may be the primary indication for performing the study. The interpretation of these findings would depend of aortic root and ascending aorta dimensions on the nature of the abnormality found and the http://heart.bmj.com/ is essential for defining the need for aortic root/ overall clinical scenario. ascending aorta surgery. Aortic dimensions by echo- For example, asymmetrical septal hypertrophy cardiography are measured using the leading edge- (ASH) usually suggests a diagnosis of hypertro- to-leading edge approach, which results in larger phic cardiomyopathy (HCM) but may also occur measurements compared with the inner edge-to- in patients with AS, hypertension and so on. inner edge approach on CT (average difference Conversely, patients with HCM may present with 28

2 mm). Furthermore, a difference of up to 3 mm concentric LV hypertrophy also. When ASH is on 17 October 2018 by guest. Protected copyright. can occur due to test–retest variation alone, regard- present, the extent of septal hypertrophy and the less of the imaging modality. Therefore, when presence and severity of the LV outflow obstruction performing serial assessment, changes <3 mm and MR need to be assessed to decide about the should be viewed with caution. need for and the choice of the intervention (alcohol septal ablation or surgical myomectomy, with or Pericardium without concomitant mitral valve repair or replace- Pericardial effusion, with or without tamponade, ment). Additionally, a septal thickness of >30 mm and constrictive pericarditis are the two most also indicates high risk for sudden cardiac death commonly encountered pericardial diseases. and the potential need for an ICD.31 In patients with pericardial effusion, the pres- In case of intracardiac masses, although the defin- ence of right atrial/right ventricular diastolic itive diagnosis requires histopathological confirma- collapse, significant respiratory variation in mitral tion, the clinical setting and the echocardiographic and tricuspid inflow velocities and dilated non-col- features themselves often provide useful clues.32 lapsing IVC suggest underlying tamponade. The For example, in a patient with rheumatic mitral size of the pericardial collection itself is not stenosis and AF, an LA or LA appendage mass is much helpful as even apparently mild effusions likely to be a thrombus, whereas a pedunculated can also produce tamponade if they accumulate mass attached to the interatrial septum is most likely rapidly. Nonetheless, the size and the location of to be a . Similarly, an LV apical mass in a the pericardial collection are important for plan- patient with previous apical infarct is most likely ning pericardiocentesis. Needle pericardiocentesis to be a thrombus. If a cardiac mass is attached to

1742 Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443 Education in Heart

10 Hare JL, Jenkins C, Nakatani S, et al. Feasibility and clinical Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from CME credits for Education in Heart decision-making with 3D echocardiography in routine practice. Heart 2008;94:440–5. Education in Heart articles are accredited for CME by various providers. To 11 Mor-Avi V, Lang RM, Badano LP, et al. Current and evolving answer the accompanying multiple choice questions (MCQs) and obtain your echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on credits, click on the ‘Take the Test’ link on the online version of the article. methodology and indications endorsed by the Japanese society of The MCQs are hosted on BMJ Learning. All users must complete a one-time echocardiography. J Am Soc Echocardiogr 2011;24:277–313. registration on BMJ Learning and subsequently log in on every visit using their 12 Geyer H, Caracciolo G, Abe H, et al. Assessment of myocardial username and password to access modules and their CME record. Accreditation mechanics using speckle tracking echocardiography: fundamentals is only valid for 2 years from the date of publication. Printable CME certificates and clinical applications. J Am Soc Echocardiogr 2010;23:351–69. 13 Plana JC, Galderisi M, Barac A, et al. Expert consensus for are available to users that achieve the minimum pass mark. multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular one of the valve leaflets, the aetiological possibili- Imaging. J Am Soc Echocardiogr 2014;27:911–39. ties would include a vegetation (infective or non-in- 14 Galli E, Lancellotti P, Sengupta PP, et al. LV mechanics in mitral and aortic valve diseases: value of functional assessment beyond fective), benign Lambl’s excrescence or papillary ejection fraction. JACC Cardiovasc Imaging 2014;7:1151–66. fibroelastoma. 15 Claus P, Omar AM, Pedrizzetti G, et al. Tissue Tracking Technology for Assessing cardiac Mechanics: principles, normal values, and Competing interests None declared. clinical applications. JACC Cardiovasc Imaging 2015;8:1444–60. Provenance and peer review Commissioned; externally peer 16 Shah AM, Claggett B, Sweitzer NK, et al. Prognostic importance reviewed. of impaired systolic function in heart failure with preserved ejection fraction and the impact of spironolactone. Circulation Author note References which include a * are considered to be a 2015;132:402–14. key reference. 17 Marwick TH, Gillebert TC, Aurigemma G, et al. Recommendations © Article author(s) (or their employer(s) unless otherwise stated in on the use of echocardiography in adult hypertension: a report the text of the article) 2017. All rights reserved. No commercial use from the European Association of Cardiovascular Imaging (EACVI) is permitted unless otherwise expressly granted. and the American Society of Echocardiography (ASE)? J Am Soc Echocardiogr 2015;28:727–54. 18 Wong CY, O’Moore-Sullivan T, Leano R, et al. Alterations of left References ventricular myocardial characteristics associated with obesity. 1 Papolos A, Narula J, Bavishi C, et al. U.S. Hospital Use of Circulation 2004;110:3081–7. Echocardiography: Insights From the Nationwide Inpatient Sample. 19 Cwajg JM, Cwajg E, Nagueh SF, et al. End-diastolic wall thickness J Am Coll Cardiol 2016;67:502–11. as a predictor of recovery of function in myocardial hibernation: 2 Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations relation to rest-redistribution T1-201 and dobutamine for the Evaluation of Left Ventricular Diastolic Function by stress echocardiography. J Am Coll Cardiol 2000;35:1152–61. Echocardiography: An Update from the American Society of *20 Baumgartner H, Hung J, Bermejo J, et al. American Society of Echocardiography and the European Association of Cardiovascular EchocardiographyEuropean Association of Echocardiography. Imaging. J Am Soc Echocardiogr 2016;29:277–314. Echocardiographic assessment of valve stenosis: EAE/ASE *3 Nishimura RA, Otto CM, Bonow RO, et al. AHA/ACC guideline recommendations for clinical practice. J Am Soc Echocardiogr for the management of patients with valvular heart disease: a 2009;22:1–23.

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27 Evangelista A, Flachskampf FA, Erbel R, et al. Echocardiography in 34 Ponikowski P, Voors AA, Anker SD, et al. ESC guidelines for the Heart: first published as 10.1136/heartjnl-2016-309443 on 7 September 2017. Downloaded from aortic diseases: EAE recommendations for clinical practice. Eur J diagnosis and treatment of acute and chronic heart failure: the Echocardiogr 2010;11:645–58. task force for the diagnosis and treatment of acute and chronic 28 Goldstein SA, Evangelista A, Abbara S, et al. Multimodality imaging heart failure of the European Society of Cardiology (ESC)developed of diseases of the thoracic aorta in adults: from the American with the special contribution of the Heart failure association (HFA) Society of Echocardiography and the European Association of of the ESC. Eur Heart J 2016;2016:2129–200. Cardiovascular Imaging: endorsed by the Society of Cardiovascular 35 Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACCF/AHA/ Computed Tomography and Society for Cardiovascular Magnetic HRS focused update incorporated into the ACCF/AHA/HRS Resonance. J Am Soc Echocardiogr 2015;28:119–82. 2008 guidelines for device-based therapy of cardiac rhythm 29 Dal-Bianco JP, Sengupta PP, Mookadam F, et al. Role of abnormalities: a report of the American college of Cardiology echocardiography in the diagnosis of constrictive pericarditis. J Am foundation/American heart association task force on practice Soc Echocardiogr 2009;22:24–33. guidelines and the heart rhythm Society. J Am Coll Cardiol 30 Sengupta PP, Krishnamoorthy VK, Abhayaratna WP, et al. Disparate 2012;2013:e6–75. patterns of left ventricular mechanics differentiate constrictive 36 Hiratzka LF, Creager MA, Isselbacher EM, et al. Surgery for aortic pericarditis from restrictive cardiomyopathy. JACC Cardiovasc dilatation in patients with bicuspid aortic valves: a statement of Imaging 2008;1:29–38. clarification from the American College of Cardiology/American 31 Gersh BJ, Maron BJ, Bonow RO, et al. ACCF/AHA guideline for Heart Association Task Force on clinical Practice guidelines. J Am the diagnosis and treatment of hypertrophic cardiomyopathy: a Coll Cardiol 2016;67:724–31. report of the American college of Cardiology foundation/American 37 Van de Veire NR, Braun J, Delgado V, et al. Tricuspid annuloplasty heart association task force on practice guidelines. Circulation prevents right ventricular dilatation and progression of tricuspid 2011;2011:e783–831. regurgitation in patients with tricuspid annular dilatation 32 Auger D, Pressacco J, Marcotte F, et al. Cardiac masses: an undergoing mitral valve repair. J Thorac Cardiovasc Surg integrative approach using echocardiography and other imaging 2011;141:1431–9. modalities. Heart 2011;97:1101–9. 38 Benedetto U, Melina G, Angeloni E, et al. Prophylactic 33 Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the tricuspid annuloplasty in patients with dilated tricuspid annulus management of valvular heart disease (version 2012). Eur Heart J undergoing mitral valve surgery. J Thorac Cardiovasc Surg 2012;33:2451–96. 2012;143:632–8. http://heart.bmj.com/ on 17 October 2018 by guest. Protected copyright.

1744 Bansal M, Sengupta PP. Heart 2017;103:1733–1744. doi:10.1136/heartjnl-2016-309443