Role Of Transthoracic Echocardiography Research Articles

Evaluation of the anatomic sinus after transcatheter aortic valve replacement

Abstract Background Transcatheter aortic valve replacement (TAVR) determines the creation of outer area between the cage and the aortic wall named the ‘anatomic sinus’ (Figure 1 A-B). This newly formed space of the sinuses of Valsalva (SOV) might disrupt the physiological currents of Valsalva and contribute to the formation of subclinical leaflets thrombosis (SLT). The evaluation of the root geometry after TAVR is generally performed with multi detector computer tomography (MDCT), and the role of transthoracic echocardiography (TTE) needs further validation. Purpose The aim of this study was to test reproducibility of 2D TTE assessment of the anatomic sinus dimension with MDCT as reference. We also investigated predictors for SLT. Methods We enrolled 90 patients who underwent TAVR with self-expandable prosthesis. 2D TTE was performed using Philips EPIQ-7, and echocardiograms analysed offline with Philips QLAB cardiac analysis. Both SOV and prosthesis diameters were assessed in long and short-axis parasternal view (PLAX / PSAX) and the bidimensional area of the anatomic sinus was calculated (Figure 2 A-B). Inter-observer (observer 1 – 2) reproducibility was assessed by the means of interclass correlation coefficient (ICC). MDCT was performed in 50 individuals to evaluate concordance (Bland Altman test) with the 2D TTE anatomic sinus area and also to detect SLT (Figure 2 C-D). Multivariable model was built to assess predictors of SLT. Results Mean follow-up was 13.1 months. There was excellent and good correlation with regard to the diameter of the SOV and the prosthesis measured in PLAX view by observer 1 and 2: ICC: 0.93, 95% Confidence Interval (CI) (0.76–0.97), p< 0.001; ICC: 0.87(0.63,0.96), p<0.001, SOV and prosthesis respectively. The correlation found with regard to the diameter of the SOV and the prosthesis measured in PSAX view was also excellent ICC: 0.90(0.68,0.97), p=0.001; and good ICC: 0.88(0.63,0.96), p <0.001, SOV and prosthesis respectively. The anatomic sinus areas assessed by 2D TTE were similar compared to areas derived by MDCT (4.1 ± 1.09 cm2 vs. 4.02 ± 1.55 cm2, respectively, p=0.57). Bland–Altman analysis of anatomic sinus area measured on 2D TTE and MDCT respectively, indicated high level of agreement and no fixed or proportional bias. Native bicuspid valve, but not the anatomic sinus area, was the only independent predictors for SLT. Conclusions Following TAVR, the newly formed anatomic sinus could be assessed with good reproducibility with 2D TTE. We found a significant association between native bicuspid valve and SLT diagnosed with MDCT.Figure 1A-BFigure 2A-D

Evaluation of the anatomic sinus after transcatheter aortic valve replacement

BackgroundFollowing transcatheter aortic valve replacement (TAVI), the newly formed ‘anatomic sinus’.may contribute to the formation of subclinical leaflet thrombosis (SLT).The evaluation of root geometry after TAVI is generally performed using multi-detector computed tomography (MDCT), and the role of transthoracic echocardiography (2D TTE) requires further validation. Thus, we aimed to test the reproducibility of 2D TTE assessment of the anatomic sinus with MDCT as a reference and its association with SLT. Methods2D TTE was performed in 90 patients, and the echocardiograms were analyzed offline. Both sinus of Valsalva (SOV) and prosthesis diameters were assessed in the long- and short-axis parasternal views (PLAX/PSAX), and the anatomic sinus area was calculated. Inter- and intra-observer reproducibility were assessed using the interclass correlation coefficient (ICC). MDCT was performed in 50 individuals to evaluate concordance with 2D TTE and to detect SLT. ResultsThere was excellent correlation regarding the diameter of the SOV and the prosthesis in PLAX (ICC: 0.93 (95% CI: 0.76,0.97); ICC: 0.80 (95% CI: 0.63,0.96)) and PSAX view (ICC: 0.90 (95% CI: 0.68,0.97); ICC: 0.88 (95% CI: 0.63,0.96)). Bland–Altman analysis of 2D TTE and MDCT anatomic sinus areas indicated a high level of agreement. SLT was detected in 8 individuals (16%); 3 patients had severe SLT at the level of 1 cusp. Conclusions2D TTE might play a role in the evaluation of the anatomic sinus after TAVI. The importance of this space and its effects on the SLT remain uncertain.

Clinical Case 29—The role of transthoracic echocardiography on patients presenting with shock of unknown etiology

Abstract Seventy-six-year-old woman, with a previous medical history of arterial hypertension, dyslipidaemia, hypothyroidism and mitral valve plasty (previous rheumatic fever) presents to the emergency department with unspecific complaints of malaise, productive cough and dyspnoea for the past 15 days. At admission, the patient was conscient, apyretic, tachycardic, hypotensive and with peripheric oxygen saturation of 90% (on room air). The patient became haemodynamically unstable and unresponsive. Electrocardiogram with sinus tachycardia, SIQIII pattern and a slight ST elevation in aVR and ST depression in DI, aVL and precordial leads. TTE revealed right cavities dilatation and the presence of a serpiginous echogenic mass that protruded from the inferior vena cava crossing the right atrium and reaching the right ventricle. Thrombolysis, fluid challenge and vasopressor perfusion were immediately started with a good clinic response. Haemodynamic stability was achieved 5 hours after the thrombolysis. An unfractionated heparin perfusion was initiated after the thrombolysis and discontinued 24 h after the patient was admitted. The remaining hospitalization was uneventful and the patient was discharged 7 days after on a non-vitamin K antagonist oral anticoagulant. TTE revaluation before discharge revealed mild dilatation of the right cavities with mild systolic dysfunction of the right ventricle and a normal PSAP. There is no scientific evidence regarding the best strategy to approach a patient with a migrating thrombus and TTE is of high value in the case of shock due to its high specificity as a rule-in test, especially when the patient cannot undergo other types of exams. Figure 1Transthoracic echocardiography (subcostal 4 chamber view) showing the presence of a serpiginous echogenic mass in the right atrium (red arrow).

Role of Echocardiography in Ductal Stenting

Patent ductus arteriosus stenting has been acknowledged as a reliable alternative to palliative shunt surgeries in neonates with duct-dependent circulation. This procedure is technically challenging and can have serious complications; hence, a thorough evaluation of the case and preprocedural planning is required. Transthoracic echocardiography (TTE) remains the first diagnostic modality for all congenital heart defects. This article focuses on the role of TTE in diagnosis and transcatheter management of duct-dependent lesions.

Preoperative echocardiography for patients with hip fractures undergoing surgery in a low-resource setting: Asset or obstacle?

The aim of this study was to determine the rate of preoperative transthoracic echocardiography in hip fracture patients and to evaluate its effects on time to surgery and length of stay. We conducted a retrospective review of all patients with hip fractures treated at a tertiary referral hospital. Data examined included age, sex, comorbidities, time to surgery, length of stay, fracture type and transthoracic echocardiography findings. Forty-eight patients with hip fractures underwent surgery (men 41.7%; mean age 77.2 (49-95)). Nine patients (18.7%) had a preoperative transthoracic echocardiography. Preoperative transthoracic echocardiography was associated with a significantly longer time to surgery an abbreviation for days e.g dys should be added after the values to indicate what time frame is being measured (14.7 versus 6.8, p = 0.0051) and length of stay (23.6 versus 10.4, p = 0.0002). This study demonstrates a high rate of preoperative transthoracic echocardiography in hip fracture patients. The role of transthoracic echocardiography should be reassessed in view of its association with significant surgical delays.

The Role of Transthoracic Echocardiography in the Evaluation of Patients With Ischemic Stroke

Background: Ischemic stroke can be classified into five etiological types, according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and its adequate investigation and characterization can aid in its clinical management and in preventing new events. Transthoracic echocardiography (TTE) plays a key role in investigating its etiology; approximately one-third of the patients remain without an adequate definition of the etiology or are classified as the undetermined TOAST type.Objectives: To evaluate if the percentage of patients with indeterminate etiology according to the TOAST classification decreased after transthoracic echocardiography, to determine whether or not the prognosis after ischemic stroke is worse among patients classified as the undetermined TOAST type, and to verify the predictive capacity of echocardiography on the prognosis after ischemic stroke.Methods: In this retrospective cohort study, clinical, neurological, and echocardiographic examinations were conducted when the patient was hospitalized for stroke. In-hospital mortality and functional capacity were evaluated at hospital discharge and 90 days thereafter. Multiple linear regression and multiple logistic regression models were adjusted for confounding factors. The level of significance was 5%.Results: A total of 1,100 patients (men = 606; 55.09%), with a mean age of 68.1 ± 13.3 years, were included in this study. Using TTE, 977 patients (88.82%) were evaluated and 448 patients (40.7%) were classified as the undetermined TOAST type. The patients who underwent TTE were 3.1 times less likely to classified as the undetermined TOAST type (OR = 0.32; p < 0.001). Echocardiography during hospitalization was a protective factor against poor prognosis, and reduced the odds of in-hospital death by 11.1 times (OR: 0.090; p < 0.001). However, the presence of the undetermined TOAST classification elevated the chance of mortality during hospitalization by 2.0 times (OR: 2.00; p = 0.013).Conclusions: Echocardiography during hospitalization for ischemic stroke reduces the chances of an undetermined TOAST classification and the risk of in-hospital mortality. However, being classified as the undetermined TOAST type increases the chance of mortality during hospitalization, suggesting that evaluating patients using echocardiography during hospitalization for acute ischemic stroke is important.

Comparison of echocardiographic findings in women with late preeclampsia and healthy pregnant women: a case–control study

Background Preeclampsia is one of the most common types of pregnancy disorders, and it is essential to know its cardiovascular complications. Therefore, we aimed to compare echocardiographic findings in women with late preeclampsia and healthy pregnant women. Method In this case-control study, 80 women with late preeclampsia and 80 healthy pregnant women were randomly selected and echocardiographic findings were determined and compared in the two groups. Results Evaluating the relationship between late preeclampsia and echocardiographic variables in pregnant women showed a significant relationship between diastolic disorder (15% in the case group vs. 5% in the control group) (p = .035), systolic artery pressure (p = .002), and TR gradient (p = .003) with late preeclampsia; However, this relationship was not observed with other echocardiographic variables (p > .05). Conclusion Since the role of transthoracic echocardiography in the management of women with preeclampsia has been emphasized by international groups, the results of this study suggest that increased TR Gradient and diastolic dysfunction are the most important echocardiography findings in patients with late preeclampsia.

The role of trans-thoracic echocardiography in the assessment of aortic annular diameter.

We aimed to compare two-dimension transthoracic echocardiogram (2D-TTE) and three-dimension transthoracic echocardiogram (3D-TTE) measurements of the aortic annular diameter using multi-detector CT (MDCT) as a gold standard.This prospective observational study included 50 consecutive patients who came to the cardiology department, Al-Azhar University Hospital, New Damietta, for MDCT coronary angiography. The study was carried out in the period from July 2016 until February 2017. All patients were subjected to informed consent, clinical history, physical examination, transthoracic echocardiography 2D and 3D, and MDCT.The aortic annular areas measured by MDCT and 3D-TTE were significantly larger than areas by 2D-TTE. A good correlation (r = 0.82) was observed between the areas obtained by 3D-TTE and MDCT; however, the correlation between the values by 2D-TTE and MDCT was rough (r = 0.30). Eccentricity Index (EI) values in 28% of the patients were greater than 0.1, that is, the aortic annulus was elliptical.Accuracy of aortic annular diameter measurement by 3D-TTE was superior to that by 2D-TTE. Three-D TTE and MDCT revealed that the shape of the aortic annulus was elliptical in 28% to 30% respectively of study subjects. There is a strong concordance between the minimum and the maximum diameter determine by 3D-TTE and MDCT.

Role of transthoracic echocardiography in the detection of atrial septal aneurysm and intracardial shunts of PFO type in ambulatory practice

Cíl: Tato studie hodnotí použitelnost transtorakální echokardiografie (TTE) jako screeningové metody k detekci aneurysmatu septa síní na souboru pacientů vyšetřených v období jednoho roku. Metodika: V období od ledna 2019 do ledna 2020 bylo ambulantně echokardiograficky vyšetřeno 769 pacientů. U 87 % z těchto pacientů s dobrou nebo velmi dobrou vyšetřitelností byla posouzena přítomnost aneurysmatu septa síní (ASA). Pokud bylo nalezeno ASA a pacient projevil zájem, byla provedena kontrastní transtorakální echokardiografie (CTTE). Výsledky: Nalezli jsme 80 pacientů s ASA, z nichž 37 podstoupilo kontrastní vyšetření. 34 z nich bylo pozitivních na přítomnost pravolevého zkratu. Kolem 18 % pacientů s ASA mělo symptomy z možné nebo z pravděpodobné kardioembolizace. Ti, jejichž symptomy byly suspektní z kardioembolizace, byli léčeni protidestičkovými léky (n = 6) nebo implantací okludéru a protidestičkovou léčbou (n = 2). Závěry: Dle této studie je prevalence ASA kolem 10 % v běžné kardiologické populaci. Podíl intrakardiálních zkratů na úrovni septa síní ve skupině pacientů s ASA byl téměř 90 %. V našem vzorku pacientů s ASA bylo kolem 18 % pacientů se symptomy z možné nebo pravděpodobné paradoxní embolizace. Na základě těchto výsledků doporučujeme zhodnotit přítomnost ASA během každého echokardiografického vyšetření a u každého pacienta s ASA provést nějakou formu kontrastního vyšetření. Všichni symptomatičtí pacienti by měli podstoupit transezofageální echokardiografii (TEE) a kontrastní transezofageální echokardiografii (CTEE). &#169; 2020, ČKS.

Comparison of transthoracic echocardiography with computed tomography in evaluation of pulmonary veins

BackgroundTransesophageal echocardiography may be used to assess pulmonary veins for atrial fibrillation ablation. No study focused on the role of transthoracic echocardiography (TTE) in evaluating the diameter and anatomy of pulmonary veins.MethodsAmong 142 atrial fibrillation patients (57.7% men; mean age, 60.5) hospitalised for catheter ablation, we assessed pulmonary veins and compared the measurements by TTE with cardiac computed tomography (CT) before ablation. Among 17 patients who had follow-up examinations, the second measurements were also studied.ResultsTTE identified and determined the diameters of 140 (98.6%) right and 140 (98.6%) left superior PVs, and 136 (95.7%) right and 135 (95.1%) left inferior PVs. A separate middle PV ostia was identified in 14 out of the 22 patients (63.6%) for the right side and in 2 out of 4 (50.0%) for the left side. The PV diameters before ablation assessed by CT vs. TTE were 17.96 vs. 18.07 mm for right superior, 15.92 vs. 15.51 mm for right inferior, 18.54 vs. 18.42 mm for left superior, and 15.56 vs. 15.45 mm for left inferior vein. The paired differences between the assessments of CT and TTE were not significant (P ≥ 0.31) except for the right inferior vein with a CT-minus-TTE difference of 0.41 mm (P = 0.018). The follow-up PV diameters by both CT (P ≥ 0.069) and TTE (P ≥ 0.093) were not different from baseline measurements in the 17 patients who had follow-up measurements.ConclusionsWith a better understanding of PV anatomy in TTE imaging, assessing PV diameters by non-invasive TTE is feasible. However, the clear identification of anatomic variation might still be challenging.

Clinical role of transthoracic and transesophageal echocardiography in transapical mitral valve repair

Objective To evaluate the role of transthoracic echocardiography(TTE) and transesophageal echocardiography(TEE) in the process of transapical mitral valve repair using a novel edge-to-edge device(ValveClamp) and this device′s efficacy and safety in a preliminary clinical trial. Methods Six patients with moderate to severe or severe degenerative mitral regurgitation (DMR) confirmed by TTE and TEE were enrolled. TTE was performed pre and post procedure as well as 30 days post procedures.Related cardiac structure and hemodynamic parameters, including mitral regurgitation area(MRA-max), vena contracta width(VCW), mitral valve effective orifice area(MVEOA), left ventricular end diastolic diameter(LVEDD), left ventricular end systolic diameter(LVESD), left ventricular ejection fraction(LVEF), max and mean mitral valve pressure gradient(MVPG-max and MVPG-mean) were recorded and evaluated in a central core laboratory. Results All the procedures were successfully performed.MRA-max, VCW and MVEOA decreased significantly post procedures (all P 0.05). Meanwhile, MVPG-max and MVPG-mean slightly increased (all P 0.05). Conclusions Transapical mitral valve repair using ValveClamp can be performed safely and a significant reduction in mitral regurgitation can be achieved in patients with DMR. TEE and TTE facilitate the patient selection for ValveClamp procedures as well as perioperative navigation and assessment. Key words: Echocardiography, transthoracic; Echocardiography, transesophageal; Transcatheter mitral valve repair; Mitral regurgitation

Cardiac arrest and the role of transthoracic echocardiography

The role of transthoracic echocardiography (TTE) is one of the top five research priorities in prehospital critical care ( Fevang et al, 2011 ). TTE is a non-invasive diagnostic tool in cardiac arrest, using ultrasound images to visualise the real-time activity of the heart ( Hernandez et al, 2008 ). TTE has the potential to reduce the time between the onset of cardiac arrest and appropriate therapy. There are several reversible causes of cardiac arrest that can be identified by TTE in the pre-hospital environment. The method and value of identifying pulmonary emboli (PE), cardiac tamponade and hypovolaemia will be discussed. Equally, TTE can exclude certain reversible causes, indicating that the cardiac arrest is of an irreversible nature and the resuscitation attempt is futile. The application of TTE in this context will be reviewed in depth, from the current literature to the physical practicalities. As such, the aim of the present study is to clarify the role of TTE in patients suffering out-of-hospital cardiac arrest.

Optimizing the role of transthoracic echocardiography to improve the cardiovascular risk stratification: the dream of subclinical coronary artery disease detection

Detecting coronary artery disease at a subclinical level has always been a challenging task for cardiologists. Various non-invasive echocardiographic approaches such as measurements of left ventricular hypertrophy, diastolic function, left atrial enlargement, valve sclerosis and calcification, epicardial fat thickness, and pulse wave velocity have been proposed to integrate the available risk-charts. The present review is a collection of evidence that supports the role of the above mentioned features in cardiac risk stratification, summarizing the state of the art in non-invasive echocardiographic coronary risk assessment. Each parameter is presented with its strengths and weaknesses, aiming to trace the future directions for the development of a reliable non-invasive approach.

CRT-300.03 Role of Transthoracic Echocardiography in the Preoperative Evaluation of Patients with Critical Limb Ischemia Undergoing Surgical Bypass

Peripheral surgical bypass for treatment of critical limb ischemia (CLI) is associated with an increased 30-day cardiovascular event rate (8.8% MACE, 1.5% cardiac arrest, 4.7% myocardial infarction, 1.4% stroke and 2.7% death). The purpose of this study is to evaluate 30-day cardiac outcomes in CLI

The Role of Transthoracic Echocardiography in Predicting Mortality in Patients with Chronic Thromboembolic Pulmonary Hypertension

The Role of Transthoracic Echocardiography in Predicting Mortality in Patients with Chronic Thromboembolic Pulmonary Hypertension

The old and the new: the pivotal role of TTE in TAVI

Transcatheter aortic valve implantation (TAVI) has undeniably revolutionised the field of interventional cardiology regarding the treatment of aortic stenosis (AS). With promising outcomes from the recently published PARTNER 2 trial (1), involving patients at intermediate risk for surgical treatment, further growth of an already rapidly expanding field is expected. Echocardiography has a pivotal role in transcatheter therapies from the early steps when the clinical diagnosis of a valvular disease is made to the postprocedural long-term follow-up. Although the role of transoesophageal echocardiography (TOE) for either pre-procedural planning or intraoperative guidance in TAVI has been the subject of several reviews and debates, the role of the older member of the family, transthoracic echocardiography (TTE), has not been given the attention it deserves. In this issue of Echo Research and Practice, Fryearson and coworkers review the role of TTE before and following TAVI and discuss as how it helps inform clinical decision-making in TAVI (2).

A continuous murmur following a nonpenetrating chest trauma

We reported a rare case of non-penetrating chest trauma-induced fistula from the right sinus of Valsalva to the right heart chambers. The ruptured sinus of Valsalva aneurysm was diagnosed preoperatively and operated on successfully. The rarity of this case highlights the need for a precise preoperative diagnosis, the role of transthoracic echocardiography, and the importance of a prompt surgical management.

Screening of Mechanical Complications of Dilated Pulmonary Artery Related to the Risk for Sudden Cardiac Death in Patients with Pulmonary Arterial Hypertension by Transthoracic Echocardiography

In patients with pulmonary arterial hypertension (PAH), the mechanical complications of pulmonary artery (PA) enlargement are related to sudden cardiac death (SCD). The aim of this study was to investigate the prevalence of PA enlargement, the correlation of main PA (MPA) diameter with other echocardiographic parameters,and the role of transthoracic echocardiography in screening for such complications. Among 298 patients who were followed for PAH, patients with PA enlargement (>40mm) by transthoracic echocardiography were consecutively enrolled in a prospective manner. The presence of left main and airway compression, PA dissection, or PA thrombus was determined with cardiac computed tomography. Forty-six patients (15.4%; mean age, 49±14years; 32.6% men) with dilated MPAs were enrolled. Mechanical complications were present in 16 patients (34.8%). Those with complications had more dilated MPAs compared with patients without (mean PA diameter, 55.6±12.2 vs 46.7±4.3mm; P=.012). Other echocardiographic parameters of the right heart, such as right ventricular systolic pressure, showed no differences (P>.05 for all). The area under the receiver operating characteristic curve for MPA diameter was 0.750 (95% CI, 0.577-0.923; P=.009), with the highest sensitivity and specificity values for the presence of complications being 85.7% and 58.6%, respectively, according to an MPA diameter of 46.5mm. Mechanical complications related to sudden cardiac death in patients with PAH with dilated PAs are common. The overall performance of transthoracic echocardiography as a screening tool for predicting such complications appears reasonable. Given the burden of sudden cardiac death, measurement of PA diameter should be routinely included over the course of follow-up, especially in patients with PAH.

Echocardiographic diastolic function assessment is of modest utility in patients with persistent and longstanding persistent atrial fibrillation

BackgroundDetection of concurrent diastolic dysfunction (DD) may be beneficial in patients with persistent and longstanding persistent atrial fibrillation (AF). The role of transthoracic echocardiography (TTE) in assessing DD in patients with AF has not been well characterized. We sought to determine the utility of TTE in detecting elevated left atrial pressure (LAP) in patients with persistent and longstanding persistent non-valvular AF using directly measured LAP as the reference standard. MethodsWe retrospectively studied 157 patients with persistent AF and preserved left ventricular ejection fraction who underwent pulmonary vein isolation (PVI). LAP was determined in conjunction with trans-septal puncture at the time of catheter ablation. TTE was performed 1day after PVI and included two dimensional, pulse wave spectral Doppler and tissue Doppler assessments. ResultsThe clinical parameter that strongly correlated with elevated LAP is longstanding persistent AF. Four strongest TTE parameters identified to moderately correlate with LAP include 1. left atrial minimum volume (LAVmin), 2. peak velocity of early mitral diastolic inflow velocity (E), 3. pulmonary vein systolic flow velocity (PVS), and 4. ratio of early diastolic transmitral inflow velocity to mitral annular velocity at the lateral site (E/E′ lateral). ConclusionAccurate assessment of diastolic dysfunction in patients with persistent and longstanding persistent AF is difficult using TTE. A combination of LAVmin, PVS, and E might be helpful to determine elevated LAP.

Transthoracic echocardiography in women with preeclampsia

Recent literature on the role of transthoracic echocardiography in the management of women with preeclampsia is reviewed with emphasis on recommendations for its use in the life-threatening complications of acute pulmonary edema, chest pain, and hemorrhage. The diagnostic criteria for preeclampsia are closer to reaching international consensus with most guidelines now removing the mandatory requirement for proteinuria. Hemodynamic findings using transthoracic echocardiography in women with untreated preeclampsia include normal or increased cardiac output, normal or increased contractility, a nondilated left ventricle, diastolic dysfunction, increased pericardial effusions, and increased left ventricular mass. Echocardiography is recommended as a diagnostic and monitoring tool for acute hemodynamic complications of preeclampsia, such as acute pulmonary edema, significant arterial hypertension, and chest pain. Despite this there has been limited uptake of transthoracic electrocardiography into routine clinical practice in women with preeclampsia. The role of transthoracic echocardiography in the management of women with preeclampsia is emphasized by international groups. Research into the hemodynamics in preeclampsia, which demonstrates preserved ejection fraction, and diastolic dysfunction highlights its utility and acceptability by pregnant women with preeclampsia. Training of obstetric anesthesiologists in echocardiography is necessary to enable more widespread implementation of this important technology.