PRESIDENT’S MESSAGE

Save our Specialty: Embrace the Future!

James D. Thomas,MD, FASE

Do you know what keeps me up at night? Beyond the sad state ofCleveland sports, I fear that over time, echocardiography may be re-duced to a commodity procedure, something akin to the electrocar-diogram. We are already seeing the start of this with the gradualchipping away at echo reimbursement and the growth of ‘‘advanced’’imaging, like CTand MRI. Those of us who live and breathe echocar-diography know that this isn’t so: echocardiography is the single mostuseful test for assessing the structure and function of the cardiovascu-lar system, combining high spatial and temporal resolution in a porta-ble, low-cost, and completely safe procedure. But there is no questionthat the past few years have seen some buzz connected to CT andMRI, with many of our graduating fellows wanting to focus their clin-ical and academic energy on modalities other than echo. How can wefight the perception of echocardiography as ‘‘basic’’ imaging? One im-portant way is by continually renewing ourselves and embracing newtechnological advances as they come along. This doesn’t mean simplyleaping on the latest shiny echo toy, but adopting time-tested andclinically-validated advances that can truly help us to manage our pa-tients. I’d like to highlight three areas that we as echocardiographersshould be integrating into our daily clinical practice: (1) contrast forleft ventricular opacification; (2) three-dimensional (3D) echocardi-ography; and (3) strain imaging.

First, let’s talk about contrast. There have been ups and downs inthe 25 year history of microbubbles for cardiac ultrasound. Remem-ber the halcyon days of the late 90s, whenmyocardial perfusion echo-cardiography was going to render nuclear cardiology obsolete? Thepredicted two billion dollar market by 2000? Let’s just say, not somuch. I have a running bet with Sanjiv Kaul, started in 1999, onwhether myocardial perfusion echocardiography would out-number nuclear scans at the Cleveland Clinic. Every five years weagree to go double or nothing on the next five years, and I anticipatein a fewmore cycles I will finally collect from him and be able to retire!But a funny thing has happened in the contrast world. We now havetwo excellent agents approved by the FDA for better endocardial def-inition, the value of which has been shown repeatedly with regard toquantifying global and regional cardiac function, identifying thrombiand other masses within the heart, rapidly diagnosing ventricularpseudoaneurysms, and helping to augment Doppler signals. Andthe safety alarms from several years ago have been largely silencedbased on several large studies and the FDA’s softened warning. Thereis no question that having a liberal policy for using contrast for left ven-tricular opacification in resting and stress echocardiograms will greatlyreduce the number of nondiagnostic studies andwill savemoney overthe long run by eliminating the need for other imaging tests. Contrastreimbursement is also one of our shining advocacy victories of thepast year, with a $58 increase in reimbursement for contrast-enhanced echocardiography in the hospital outpatient setting. Thismeans there is now a $164 increment when a transthoracic echo isaugmented with contrast, more than enough to pay for the contrastand the costs of administering it. And myocardial perfusion? My betwith Sanjiv notwithstanding, this really does work, and somedaymay be a routine clinical procedure.

The second key technology we need to embrace is 3D echocardi-ography. 3D echo has been such a long time coming that a few yearsago ASE (and ACC) Past-President Tony Demaria remarked, ‘‘A childcan be promising for just so long.’’ However, I do believe that at longlast this child is finally achieving great things. There are two broad

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areas that 3D echo has impacted in daily echo-cardiographic practice. First, it has been provenagain and again that cardiac volumes mea-sured by 3D imaging are much more accuratethan those based on two-dimensional (2D)echo with its geometric assumptions. When isthis important? Consider a patient after myo-cardial infarction, where an ejection fractionless than 35% indicates the need for an im-plantable cardiac defibrillator. The secondbroad application of 3D echo is in the assess-ment of valvular heart disease, where non-planar structures cannot be fully defined by

2D imaging. Three-dimensional echocardiography, especially transe-sophageal, provides an unparallel view of valve function, allowing theoperator to determine exactly which scallop of a mitral valve isprolapsing, and to measure precisely the size of the aortic annulusto guide transcutaneous aortic valve replacement.

Three-dimensional echo is also the ideal way to guide complexinterventions in the cath lab. When an interventionalist tries to passa wire through a paravalvular leak, fluoroscopic imaging is almostworthless, but 3D can show the wire and the defect precisely, allow-ing the operator to guide the wire more accurately and intuitively.Three-dimensional echo has always been on the technological cuttingedge, from the early days of sequential acquisition of 2D planes withoff-line reconstruction, to the current real-time volumetric imagingwith massively parallel processing of multiple ultrasound beams si-multaneously. With continued improvement in computer powerand intelligent image processing, it is now possible to obtain accuratevolumes of the heart in just a few seconds and to instantly see com-plex 3D structures in a variety of projections. In order to integrate3D imaging into busy clinical laboratories, it is important for both so-nographers and physicians to educate themselves, either at live pro-grams or on-line, where techniques for manipulating 3D data setsare taught. Once 3D echo is integrated into a laboratory, it can bedone without significant increase in the duration of a study, and theimproved diagnostic accuracy will greatly aid patient care.

The final technology that we need to embrace is advanced me-chanical imaging with strain and strain rate imaging. Again, this isa tool that has previously been relegated largely to research studies,but the time has come to bring it into daily clinical practice. Studiesin the last few years have shown that strain imaging can localize myo-cardial infarctions, provide evidence for myocardial viability, and de-tect subclinical left ventricular dysfunction in valvular heart disease.One of the most important applications is in the cardio-oncologyrealm, where a small reduction in absolute global longitudinal straincan predict future left ventricular dysfunction in patients undergoingcancer chemotherapy. While this approach is still evolving, at theCleveland Clinic we now study all patients undergoing cardiotoxicchemotherapy with regular strain imaging and 3D quantitative ech-oes, augmented by contrast, with whichwe can detect early reductionin ventricular function and react before this is irreversible.

So there you have it: three tools that are right in our hands andready to impress the clinical world as well as those who pay for it.By embracing new technology and doing our very best to apply itto complex clinical problems, we can assure the viability of echocar-diography for years to come.

ournal of the American Society of Echocardiography 19A