Hindawi Publishing Corporation

BioMed Research International

Volume 2013, Article ID 310483, 11 pages
http://dx.doi.org/10.1155/2013/310483

Review Article
Echocardiography in the Era of Multimodality
Cardiovascular Imaging

Benoy Nalin Shah1,2

1
Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
2
National Heart & Lung Institute, Imperial College, London SW7 2AZ, UK

Correspondence should be addressed to Benoy Nalin Shah; [email protected]

Received 11 April 2013; Accepted 11 June 2013

Academic Editor: Dirk Bandorski

Copyright © 2013 Benoy Nalin Shah. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Echocardiography remains the most frequently performed cardiac imaging investigation and is an invaluable tool for detailed and
accurate evaluation of cardiac structure and function. Echocardiography, nuclear cardiology, cardiac magnetic resonance imaging,
and cardiovascular-computed tomography comprise the subspeciality of cardiovascular imaging, and these techniques are often
used together for a multimodality, comprehensive assessment of a number of cardiac diseases. This paper provides the general
cardiologist and physician with an overview of state-of-the-art modern echocardiography, summarising established indications as
well as highlighting advances in stress echocardiography, three-dimensional echocardiography, deformation imaging, and contrast
echocardiography. Strengths and limitations of echocardiography are discussed as well as the growing role of real-time three-
dimensional echocardiography in the guidance of structural heart interventions in the cardiac catheter laboratory.

1. Introduction the emerging role of real-time echocardiography for guidance

of interventional procedures.
The beginning of the twenty-first century in cardiovascular
imaging has been dominated by one theme: “multimodality.”
It is currently the buzz word of imaging, as the “traditional” 2. The Evolution of Cardiac Ultrasound
techniques of echocardiography and nuclear cardiology have
been complimented by the more “modern” techniques of Echocardiography has witnessed dramatic improvements in
cardiovascular magnetic resonance (CMR) and cardiac- technology over the past 25 years. Aside from the plain chest
computed tomography (CCT). Cardiovascular imaging has X-ray, it remains the primary—and thus most frequently
seen an unprecedented growth in demand, fuelled by tech- performed—cardiac imaging investigation. A wealth of struc-
nological advances and wider availability of these modalities tural (anatomical) and haemodynamic (physiological) infor-
[1]. Each of these techniques has strengths and weaknesses mation can be ascertained from one examination. From
(Table 1) and, in combination, they are used widely in the the one-dimensional M-mode echocardiogram to real-time
management of patients with coronary heart disease, valvular three-dimensional imaging, an echocardiographic study in
heart diseases, heart failure, congenital heart disease, and 2013 can reveal physiology and pathology in detail previously
arrhythmias. The aim of this review is to provide a compre- unimaginable.
hensive overview of contemporary echocardiography for the The numerous modalities within echocardiography fur-
general cardiologist and physician, summarising established nish the scanning sonographer or physician with a wide array
indications with the supporting evidence and also highlight- of technologies for complete assessment of cardiac morphol-
ing recent technological advances within the subspeciality, ogy and function. The high temporal resolution of M-mode
particularly in stress three-dimensional echocardiography, echocardiography permits accurate depiction of rapidly mov-
deformation imaging and contrast echocardiography, and ing structures and retains relevance in today’s practice.
2 BioMed Research International

Table 1: A summary table comparing the four main modalities in cardiac imaging.

Echocardiography Nuclear cardiology CMR CCT

Availability +++ ++ ++ ++
Cost + ++ ++ ++
Ionising radiation − ++ − ++
Extracardiac information + + +++ +++
Coronary artery assessment + − ++ +++
Assessment of systolic function +++ ++ +++ ++
Assessment of diastolic function +++ + + +
Assessment of valvular function +++ − ++ +
Physiological stress testing + + − −
Pharmacological stress testing + + + −
Contraindication − − Most implanted devices −
Limited by renal failure − − + +
Risk of claustrophobia − + ++ +

2D transthoracic echocardiography (TTE) forms the basis and thirdly, and possibly most importantly, the availability
of visual assessment of cardiac chambers and valves and of ultrasound contrast agents for improved visualisation of
permits identification of structural abnormalities. Doppler the endocardial border and LV cavity during rest and stress
echocardiography, comprising spectral Doppler (pulsed wave imaging [7].
and continuous wave) and colour Doppler imaging, identi- SE has numerous advantages as a stress technique but also
fies the direction, velocity, amplitude, and timing of blood some disadvantages. Its advantages include the ubiquitous
flow through the heart. This information has an enormous availability of echocardiography machines and thus the low
number of uses—Doppler echocardiography remains the cor- infrastructure cost, lack of exposure to ionising radiation,
nerstone of evaluating the severity of stenotic and regurgitant safety, multiple stressor options (physiological (treadmill
valve diseases, estimating LV filling pressures (and thus con- or bicycle) or pharmacological (inotropes or vasodilators)),
firming the diagnosis of diastolic dysfunction and, in symp- portability, and the substantial supporting evidence base
tomatic patients, heart failure with preserved ejection frac- accrued over the past 20 years. The option of performing
tion), detection of intracavity and subvalvular obstruction physiological stress is important, as this should always be the
in hypertrophic cardiomyopathy, and for identification of preferred stress technique in an attempt to reproduce patient’s
intracardiac shunts (e.g., septal defects). symptoms and also determine their functional aerobic capac-
Transoesophageal echocardiography (TOE) permits de- ity. Disadvantages include a lower sensitivity than perfusion
tailed views of most cardiac structures and has a very wide techniques and suboptimal image quality in some patients
number of indications, from exclusion of atrial appendage despite use of ultrasound contrast.
thrombus prior to cardioversion through to investigation of In the United Kingdom, SE is now—along with myocar-
suspected cardioembolic stroke [2]. In most centres, TOE dial perfusion scintigraphy and CMR—recommended over
remains the imaging technique of choice for precise assess- exercise electrocardiography (ex-ECG) for the investigation
ment of mechanisms and severity of valvular heart disease of patients with chest pain suspected to be angina pectoris [8].
and their associated complications (Figure 1). Although semi- A randomised controlled trial showed that SE is more cost-
invasive in nature, TOE is generally well tolerated and has an effective than ex-ECG for establishing the diagnosis of CAD
excellent safety profile [3, 4]. in patients hospitalised with chest pain [9], and a recent large,
real-world study of the incorporation of SE into a chest pain
unit has confirmed the feasibility and prognostic value of this
3. Specific Advances approach in routine practice [10].
3.1. Stress Echocardiography. Stress echocardiography (SE) There is also now growing appreciation of the potential
has progressed significantly over the past three decades clinical value of SE for “noncoronary” applications (see
to become one of the most widely utilised imaging tech- Table 2), in particular the dynamic assessment of valvular
niques for evaluation of patients with known or suspected heart diseases. These patients have traditionally been evalu-
coronary artery disease (CAD). Once heavily criticised for ated by resting echocardiography only, although their symp-
being too “operator dependent,” several technical advances toms are typically induced by exertion. Exercise echocardio-
have dramatically improved the accuracy—and reduced graphy can be used to risk stratify asymptomatic patients
variability—of SE. These include firstly the advent of tissue with severe aortic stenosis (AS). Stress-induced increases in
harmonic imaging, which was shown to improve diagnostic mean transaortic gradient [11, 12] and pulmonary pressures
accuracy for detection of CAD over fundamental frequency [13] are associated with worse outcome. Furthermore, low-
imaging in exercise [5] and dobutamine [6] SE, secondly the dose dobutamine stress echocardiography is frequently used
introduction of digital cine loop acquisition with side-by- to differentiate true severe AS from “pseudosevere” AS in
side display of rest and stress images for ease of comparison, patients with low-flow low-gradient aortic stenosis [14].
BioMed Research International 3

LA
LV

LV Ao

RA
LA

(a) (b)

AoV

(c) (d)

Figure 1: A patient with previous mitral valve repair attended with increasing breathlessness. 2D-TTE revealed two jets of mitral regurgitation
(panel (a)). 2D-TOE suggested the presence of a paravalvular leak (panel (b), see arrows). Three-dimensional TOE revealed dehiscence of
the posterior aspect of the mitral annuloplasty ring (panel (c), see arrow), and real-time 3D colour during TOE confirmed the presence of
a reguritant jet (arrow) through this defect (panel (d)). The patient subsequently underwent redo mitral valve surgery. (LA: left atrium; RA:
right atrium; LV: left ventricle; Ao: aorta; AoV: aortic valve).

Table 2: Contemporary indications for stress echocardiography.

Indication Parameter(s) measured

Coronary applications
Myocardial ischaemia Wall thickening at rest versus stress
Myocardial viability Wall thickening at rest, low-dose, and peak stress
Noncoronary applications
(A) Valve disease

Asymptomatic severe AS Exercise-induced change in mean transaortic gradient

Exercise-induced change in peak transtricuspid gradient
Low-flow low-gradient AS LVOT and AoV VTI at rest and low-dose dobutamine stress
Symptomatic mild/moderate MS Exercise-induced change in mean transmitral and transtricuspid gradients
Symptomatic moderate MR Exercise-induced changes in EROA and pulmonary pressures
(B) Cardiomyopathy
HCM Exercise-induced dynamic LVOT obstruction
DCM Contractile reserve in response to low-dose dobutamine
Assessment of global LV contractile reserve
ICM Assessment of viability in posterolateral walls (for guiding LV lead placement)
Assess exercise capacity objectively
Assess inducibility of tachyarrhythmias
(AS: aortic stenosis; MS: mitral stenosis; MR: mitral regurgitation; LVOT: left ventricular outflow tract; AoV: aortic valve; EROA: effective regurgitant orifice
area; VTI: velocity time integral; HCM: hypertrophic cardiomyopathy; DCM: dilated cardiomyopathy; ICM: ischaemic cardiomyopathy).
4 BioMed Research International

Rest Rest

(a) (b)

Stress Stress

(c) (d)
Figure 2: A patient with moderate mitral stenosis but worsening exertional dyspnoea underwent exercise SE. At rest, mean transmitral
gradient was 5 mm Hg (a), and transtricuspid pressure gradient was 24 mm Hg (b). After 7-minute BRUCE protocol treadmill exercise, mean
transmitral gradient significantly increased to 27 mm Hg (c) and transtricuspid pressure gradient had more than doubled to 51 mm Hg (d).
The patient subsequently underwent balloon mitral valvuloplasty with excellent symptomatic relief.

Exercise SE is also helpful in certain patients with mitral remodelling following cardiac resynchronisation therapy
valve disease. Patients with mitral stenosis (MS) who have [19].
symptoms disproportionate to the degree of MS at rest (e.g.,
marked exertional dyspnoea but only moderate MS at rest) 3.2. Three-Dimensional Echocardiography. Three-dimen-
should undergo exercise SE—an increase in mean transmitral sional (3D) echocardiography is widely perceived as a novel
gradient to >15 mm Hg or pulmonary artery pressure to technique, but the initial work on 3D echocardiography dates
>60 mm Hg is an indication for valve intervention (Figure 2). back three decades [20, 21]. However, significant technical
The dynamic nature of ischaemic mitral regurgitation (MR) advances have reduced the size of the transducer, improved
was previously shown in a quantitative Doppler echocardio- speed of image processing, and, importantly, allowed real-
graphy study, using exercise stress in patients with ischaemic time 3D imaging. This has been made possible with the
cardiomyopathy (ICM) recently admitted with pulmonary advent of fully sampled matrix array transducer technology
oedema and comparing with ICM patients without pul- [22].
monary oedema [15]. Patients with recent pulmonary oedema 3D-TTE has numerous proven uses in clinical practice. It
had significantly greater increases in MR and pulmonary has been shown to be superior to 2D-TTE and equal to CMR
pressures during exercise than those without pulmonary for assessment of ventricular volumes [23], cardiac mass [24],
oedema. The same group has also demonstrated the clinical and calculation of ejection fraction [25]. The latter is espe-
value of exercise SE in patients with degenerative MR [16]. A cially useful clinically in patients that require serial EF
recent analysis clearly indicated the value of SE in valve dis- assessment (e.g., cancer patients receiving chemotherapeutic
ease in daily clinical practice and also suggested expansion of agents with potential cardiotoxicity) as 2D-TTE can suffer
SE in valve disease beyond that indicated by current guide- from underestimation of true volumes due to chamber fore-
lines [17]. shortening. 3D-TTE has also been used to assess ventricular
Aside from valvular heart disease, exercise SE can also be mechanical dyssynchrony [26], and, of clinical relevance,
used in patients with hypertrophic cardiomyopathy to reveal dyssynchrony demonstrated by real-time 3D-TTE can predict
dynamic left ventricular outflow tract obstruction (Figure 3) long-term response to cardiac resynchronization therapy
[18]. Finally, myocardial contractile reserve, determined by [27]. 3D-TTE has also been proved to be valuable in assess-
SE, can identify those patients that will experience LV reverse ment of valvular heart disease—it can provide information
BioMed Research International 5

(a) (b)

(c)

Figure 3: A 47-year-old man with hypertrophic cardiomyopathy underwent exercise SE. At rest, peak gradient across the aortic valve was
12 mm Hg (panel (a)). Repeat assessment during a held Valsalva manoeuvre revealed that the peak gradient was now 63 mm Hg (panel (b)),
which indicates that exercise-induced LVOT obstruction is highly likely. This was indeed confirmed that at peak stress, the maximum gradient
had increased to 135 mm Hg (panel (c)). Note the late systolic peaking of the Doppler profile in panels (b) and (c), indicative of dynamic rather
than fixed outflow tract obstruction. The patient was commenced on beta-blocker therapy following the test results.

previously only easily determined by TOE (e.g., mitral valve excursion, is important in assessment ventricular function is
scallop assessment in mitral regurgitation). The accuracy of also not new—M-mode echocardiography was used to relate
calculation of aortic valve area in aortic stenosis has also been myocardial velocity to ventricular function in the 1970s [30].
shown to be improved by using 3D-TTE due to more precise Tissue Doppler imaging (TDI) and speckle tracking
assessment of outflow tract dimensions [28]. echocardiography (STE) are techniques that permit detailed
The most significant advance, however, has been in analysis of regional as well as global cardiac function through
3D-TOE [29]. Real-time, 3D zoom, and live 3D imaging pro- unique temporal and spatial data processing. TDI deliberately
vide unique views of the heart and allow superior detection of filters out the low amplitude, high frequency signals from the
pathology, especially valvular diseases. 3D echocardiography blood-pool in order to allow analysis of the high amplitude,
is most valuable in cases of complex pathology. A simple P2 and low frequency signals from myocardium itself [31]. TDI is
prolapse of the mitral valve is usually evident from 2D imag- most frequently used to assist in determining diastolic func-
ing, but a combination of flail scallop(s) and prolapse +/− tion and LV filling pressures by means of the 𝐸/𝐸󸀠 ratio [32]
chordal rupture may be more challenging on 2D, and any (where 𝐸󸀠 is the early motion of the mitral annulus back
confusion is usually dispelled with 3D imaging. As discussed towards the cardiac base from the apex). The longitudinal
in the following, the feasibility of real-time 3D-TOE has made function of both ventricles is also assessed with TDI, where 𝑆󸀠
it an essential adjunct in guiding invasive procedures in the represents the peak systolic velocity of the left or right ventri-
catheter laboratory also. cle. These parameters have become routine measurements in
clinical practice due to a combination of their reproducibility
3.3. Deformation Imaging: “Myocardial Mechanics”. The and diagnostic and prognostic importance.
complex orientation of myocardial fibres—radial, circumfer- STE is based on the principle of following (or tracking)
ential, and longitudinal—has been recognised for a long time. the unique “speckle pattern” of a myocardial segment through
The theory that tissue motion, as opposed to endocardial the cardiac cycle (see Figure 4). One advantage of STE is that
6 BioMed Research International

(a) (b)

(c) (d)

Figure 4: Examples of strain imaging using speckle tracking echocardiography. On the top row are images from a normal healthy volunteer
(apical 4-chamber view on the left and summary strain scores with bulls-eye plot on the right), and on the bottom row are corresponding
images from a patient with severe ischaemic cardiomyopathy. Note that the healthy volunteer has normal longitudinal strain in all segments
with a global strain score of −18.9%, whereas the cardiomyopathy patient has highly abnormal strains with a significantly depressed global
strain score of just −5.0%.

it removes the possibility of falsely designating myocardium placement of LV leads [41]. TDI can also be used to assess
as having normal function when “velocity” is in fact due to cardiac dyssynchrony. This has become a controversial topic;
tethering (e.g., adjacent scar) or translational motion due to however, as the PROSPECT trial [42] suggested no echocar-
movement of the whole heart (both potential limitations of diographic parameter(s) could accurately predict favourable
TDI [33]). Both TDI and STE can be used to measure myocar- response to biventricular pacing, though numerous author-
dial strain, a dimensionless quantity defined as the unit ities worldwide were quick to highlight surprisingly funda-
change in length of an object relative to its original length. mental flaws in the trial’s methodology [43].
Strain rate is its derivative with respect to time (i.e., rate of Potentially of great clinical relevance is the fact that STE
change of strain and usually expressed as 1/sec (or sec−1 )). In can reveal subclinical LV dysfunction in hearts with appar-
normal myocardial segments, there is shortening in systole ently normal systolic function, as measured by EF, and thus
(negative strain and strain rates) and lengthening in diastole could have a role in detecting cardiac involvement in systemic
(positive strain and strain rates) as cardiomyocytes return to diseases [44], unusual or rare conditions [45], and also for
their resting state [33]. detecting early evidence of cardiotoxicity in cancer patients
A wealth of data has been accumulated on the potential receiving chemotherapy [46]. At present, strain and strain
clinical value of strain and strain rate assessment in a number rate imaging remains predominantly research tools but shows
of cardiac diseases [34]. Normal ranges have also been considerable promise for translation into clinical practice.
defined [35]. STE-derived strain imaging has been shown The limitations of STE include the requirement of good
to have additive benefit for detection of CAD in patients image quality and variability between different software and
undergoing dobutamine SE [36], and the superior ability of hardware manufacturers.
strain imaging to predict outcome in patients undergoing
dobutamine SE has also been shown [37]. Strain imaging is an
accurate technique for detecting viable myocardium, particu- 3.4. Contrast Echocardiography. Ultrasound contrast agents
larly when strain parameters are assessed at rest and following (UCAs) consist of gas-filled microspheres which display
low-dose dobutamine SE [38, 39]. Strain imaging has also unique acoustic properties when exposed to ultrasound
been studied extensively for detecting dyssynchrony and thus waves. Contrast bubbles resonate when exposed to an ultra-
predicting response to cardiac resynchronisation therapy sound wave. This is predominantly a nonlinear oscillation
[40]. Recently, it was shown that targeted placement of the LV (i.e., expansion and contraction of the bubble are not equal)
pacing lead to the site of latest mechanical activation—as at the ultrasound frequencies used in diagnostic imaging.
elucidated by STE—was associated with favourable reverse Microbubbles are several million times more effective at
remodelling, fewer repeat hospitalizations, and improved scattering sound than red blood cells, resulting in a greatly
functional capacity compared to patients with standard enhanced “blood pool” signal [47]. The blood pool agents
BioMed Research International 7

(a) (b)

(c) (d)
Figure 5: Apical 4-chamber images taken before ((a) and (b)) and after ((c) and (d)) ultrasound contrast injection in a patient attending for
routine transthoracic echocardiography. At rest, endocardial definition at end diastole (a) and end systole (b) was poor and did not permit
quantitation of ejection fraction or assessment of regional (segmental) function. Following a single bolus injection of contrast, endocardial
border visualisation was significantly improved at end diastole (c) and end systole (d), allowing regional and global systolic assessments.

developed consist of a gaseous material encapsulated within confer greater stability. They are used to produce a stronger
a stabilizing outer shell. These microbubbles are typically ultrasonic signal than that generated by tissues and, thus, are
slightly smaller than erythrocytes, allowing free passage most commonly used to improve image quality (Figure 5).
within the circulation and effectively acting as red cell tracers There is ample evidence demonstrating that UCAs
[48]. improve estimation of global [50] and regional [51] LV sys-
The first generation UCAs consisted of air surrounded by tolic functions. UCAs improve the accuracy of measurement
an albumin shell [49]. Unfortunately, these agents had a very of LV volumes and ejection fraction also [52, 53]. As UCAs
short lifespan in vivo and thus had limited utility in diagnostic improve overall image quality, they also help detect structural
tests. The second generation of UCAs addressed this issue abnormalities such as noncompaction cardiomyopathy [54],
by changing both components of microbubbles—the air was apical hypertrophic cardiomyopathy [55], and left ventric-
replaced by inert gases with high molecular weight, high ular thrombus [56]. Their biggest use, however, is in stress
density, and low solubility, such as sulphur hexafluoride echocardiography. The use of contrast significantly reduces
(SonoVue) or perfluorocarbons (e.g., Optison or Definity). the number of “uninterpretable” studies [7] and thus is cost-
The outer shell is now made using phospholipids, which also effective as it reduces additional testing [57]. This has helped
8 BioMed Research International

establish stress echocardiography as a front-line investigation and combine quick thinking with speedy manual dexterity.
in assessment of patients with known or suspected coronary This skill set is not necessarily acquired during conventional
artery disease. training. He/she may be called upon to provide urgent infor-
The majority (90%) of the blood within the myocardial mation in case of sudden unexplained patient deterioration
walls reside within capillaries [58]. Thus the intensity of the (e.g., sudden hypotension during TAVI due to entanglement
contrast signal, when the myocardium is fully saturated with of the delivery system in the mitral subvalvular apparatus
contrast, reflects the concentration of microbubbles within causing acute severe mitral regurgitation). The need for such
myocardial capillaries [59] and, consequently, capillary or individuals is likely to be restricted to tertiary units, but
myocardial blood volume. Appreciation of this fact led to the in large centres one can imagine such a person spending
recognition that echocardiography could be used to assess a significant amount of time in the cardiac catheter lab-
myocardial perfusion, a technique now known as myocardial oratories. Appropriate training will be required to ensure
contrast echocardiography (MCE). A high intensity (high that we produce cardiologists capable of performing such
mechanical index) “flash” or impulse is used to destroy the studies—hence one can envisage the birth of a super-special-
microbubbles in the myocardial capillaries, and their rate of ity of “interventional echocardiology.”
replenishment is observed. Delayed replenishment manifests
as a perfusion defect and is the hallmark of ischaemia during
5. Limitations
MCE. The first papers on MCE dates back to three decades
[60, 61], and since then, it has accumulated a large evidence Echocardiography does have certain limitations, which merit
base to support its use in the detection of CAD [62]. Finally, discussion. The greatest advantage of cross-sectional imaging
as presence of contrast denotes vascularity, UCAs can also be (i.e., CMR and CCT) over echocardiography is the informa-
used in patients with intracardiac masses in order to distin- tion available on extracardiac structures. The aorta, aortic
guish between avascular masses (e.g., thrombus) and vascular arch, pulmonary artery, and pulmonary veins are far more
masses such as tumours [63]. clearly seen by these modalities and are often poorly seen or
not seen at all by echocardiography. Thus, assessment of pul-
monary veins in patients awaiting an atrial fibrillation abla-
4. ‘‘Interventional Echocardiology’’: Dawn of tion procedure, assessment of the aortic arch and descending
a New Super-Specialty? thoracic aorta in patients with chronic aortic dissection or
coarctation, and serial assessment of patients with previous
The advances in 3D echocardiography—in particular the coarctation repair, for example, will generally be performed
advent of a fully sampled matrix array transducer allowing by CMR or CCT.
real-time 3D-TOE—has brought the echocardiologist to the Echocardiography can also suffer from poor image qual-
forefront of catheter-lab-based procedures in structural heart ity, despite the use of ultrasound contrast agents. This is most
disease. Real-time 3D-TOE is now considered by many a pre- often seen in patients who are extremely underweight or over-
requisite for guidance of percutaneous treatment of aortic weight, but also in patients with chronic airways disease or
stenosis (transcatheter aortic valve implantation (TAVI)), chest wall deformities (e.g., pectus excavatum). Patients on
mitral regurgitation (e.g., MitraClip devices), closure of the intensive care units, who are frequently supine and may be
left atrial appendage and of atrial septal defects (ASDs and mechanically ventilated, also often have challenging TTE
PFOs). The incremental value of 3D-TOE over 2D-TOE images, although TOE can resolve such difficulties.
during TAVI procedures was recently demonstrated in a
large single-centre study [64]. Indeed, real-time 3D-TOE is
6. Conclusion
expanding its use further and, for example, has been used
to guide electrophysiological procedures such as ablation of Echocardiography permits accurate assessment of myocar-
atrial flutter and fibrillation (helping reduce significantly the dial structure, function and perfusion. Echocardiography is
use of fluoroscopy) [65]. thus in itself a multimodality imaging technique. The field
Intracardiac echocardiography (ICE), performed in the of echocardiography is diverse and encompasses numerous
catheter laboratory using single-use percutaneous 2D probes individual techniques—some with established clinical value,
introduced transvenously (e.g., via the femoral vein), is also whilst others show much promise in research. The expanding
widely used to guide interventions [66]. Its biggest advantage role of echocardiography within current clinical practice is
over TOE is the ability to obtain similar echo views without underpinned by continual technological advances and justi-
the need for general anaesthesia, with its attendant costs and fied by the accumulating evidence of clinical value of these
potential risks. Therefore, ICE has been used in preference to techniques when utilised in daily practice.
TOE for a number of procedures, including atrial fibrillation
[67] and ventricular tachycardia [68] ablation procedures,
References
closure of septal defects [69], TAVI procedures [70] and to
guide CRT procedures [71]. However, the significant limita- [1] L. J. Shaw, T. H. Marwick, W. A. Zoghbi et al., “Why all the focus
tion of ICE is expensive, given that the probes must be dis- on cardiac imaging?” JACC: Cardiovascular Imaging, vol. 3, no.
posed of after a single use. 7, pp. 789–794, 2010.
The echocardiologist performing such studies needs to [2] F. A. Flachskampf, L. Badano, W. G. Daniel et al., “Recommen-
have a sound grasp of normal cardiac and valvular anatomy dations for transoesophageal echocardiography: update 2010,”
BioMed Research International 9

European Journal of Echocardiography, vol. 11, no. 7, pp. 557–576, [16] J. Magne, P. Lancellotti, and L. A. Piérard, “Exercise-induced
2010. changes in degenerative mitral regurgitation,” Journal of the
[3] W. G. Daniel, R. Erbel, W. Kasper et al., “Safety of transesophag- American College of Cardiology, vol. 56, no. 4, pp. 300–309, 2010.
eal echocardiography. A multicenter survey of 10,419 examina- [17] S. Bhattacharyya, V. Kamperidis, B. N. Shah et al., “152 Clinical
tions,” Circulation, vol. 83, no. 3, pp. 817–821, 1991. utility and prognostic value of appropriateness criteria in stress
[4] J. N. Hilberath, D. A. Oakes, S. K. Shernan, B. E. Bulwer, M. N. echocardiography for evaluation of valvular heart disease,”
D’Ambra, and H. K. Eltzschig, “Safety of transesophageal echo- Heart, vol. 99, pp. A89–A90, 2013.
cardiography,” Journal of the American Society of Echocardiog- [18] B. J. Gersh, B. J. Maron, R. O. Bonow et al., “2011 ACCF/AHA
raphy, vol. 23, no. 11, pp. 1115–1127, 2010. guideline for the diagnosis and treatment of hypertrophic cardi-
[5] D. G. Skolnick, S. G. Sawada, H. Feigenbaum, and D. S. Segar, omyopathy,” Journal of the American College of Cardiology, vol.
“Enhanced endocardial visualization with noncontrast har- 58, no. 25, pp. e212–e260, 2011.
monic imaging during stress echocardiography,” Journal of the [19] P. Lancellotti, M. Senechal, M. Moonen et al., “Myocardial con-
American Society of Echocardiography, vol. 12, no. 7, pp. 559–563, tractile reserve during exercise predicts left ventricular reverse
1999. remodelling after cardiac resynchronization therapy,” Euro-
[6] F. B. Sozzi, D. Poldermans, J. J. Bax et al., “Second harmonic pean Journal of Echocardiography, vol. 10, no. 5, pp. 663–668,
imaging improves sensitivity of dobutamine stress echocar- 2009.
diography for the diagnosis of coronary artery disease,” The [20] M. Matsumoto, M. Inoue, S. Tamura, K. Tanaka, and H. Abe,
American Heart Journal, vol. 142, no. 1, pp. 153–159, 2001. “Three-dimensional echocardiography for spatial visualization
[7] J. C. Plana, I. A. Mikati, H. Dokainish et al., “A randomized and volume calculation of cardiac structures,” Journal of Clinical
cross-over study for evaluation of the effect of image optimiza- Ultrasound, vol. 9, no. 4, pp. 157–165, 1981.
tion with contrast on the diagnostic accuracy of dobutamine [21] K. H. Sheikh, S. W. Smith, O. von Ramm, and J. Kisslo, “Real-
echocardiography in coronary artery disease. The OPTIMIZE time, three-dimensional echocardiography: feasibility and ini-
trial,” JACC: Cardiovascular Imaging, vol. 1, no. 2, pp. 145–152, tial use,” Echocardiography, vol. 8, no. 1, pp. 119–125, 1991.
2008.
[22] L. Sugeng, L. Weinert, K. Thiele, and R. M. Lang, “Real-time
[8] J. S. Skinner, L. Smeeth, J. M. Kendall, P. C. Adams, and A. three-dimensional echocardiography using a novel matrix array
Timmis, “NICE guidance. Chest pain of recent onset: assess- transducer,” Echocardiography, vol. 20, no. 7, pp. 623–635, 2003.
ment and diagnosis of recent onset chest pain or discomfort of
suspected cardiac origin,” Heart, vol. 96, no. 12, pp. 974–978, [23] N. P. Nikitin, C. Constantin, P. H. Loh et al., “New generation
2010. 3-dimensional echocardiography for left ventricular volumetric
and functional measurements: comparison with cardiac mag-
[9] P. Jeetley, L. Burden, B. Stoykova, and R. Senior, “Clinical and netic resonance,” European Journal of Echocardiography, vol. 7,
economic impact of stress echocardiography compared with no. 5, pp. 365–372, 2006.
exercise electrocardiography in patients with suspected acute
coronary syndrome but negative troponin: a prospective ran- [24] V. Mor-Avi, L. Sugeng, L. Weinert et al., “Fast measurement of
domized controlled study,” European Heart Journal, vol. 28, no. left ventricular mass with real-time three-dimensional echocar-
2, pp. 204–211, 2007. diography: comparison with magnetic resonance imaging,” Cir-
culation, vol. 110, no. 13, pp. 1814–1818, 2004.
[10] B. N. Shah, G. Balaji, A. Alhajiri, I. S. Ramzy, S. Ahmadvazir, and
R. Senior, “The incremental diagnostic and prognostic value [25] L. Sugeng, V. Mor-Avi, L. Weinert et al., “Quantitative assess-
of contemporary stress echocardiography in a chest pain unit: ment of left ventricular size and function: side-by-side compari-
mortality and morbidity outcomes from a real-world setting,” son of real-time three-dimensional echocardiography and com-
Circulation: Cardiovascular Imaging, vol. 6, no. 2, pp. 202–209, puted tomography with magnetic resonance reference,” Cir-
2013. culation, vol. 114, no. 7, pp. 654–661, 2006.
[11] P. Lancellotti, F. Lebois, M. Simon, C. Tombeux, C. Chauvel, and [26] S. Kapetanakis, M. T. Kearney, A. Siva, N. Gall, M. Cooklin,
L. A. Pierard, “Prognostic importance of quantitative exercise and M. J. Monaghan, “Real-time three-dimensional echocar-
Doppler echocardiography in asymptomatic valvular aortic diography: a novel technique to quantify global left ventricular
stenosis,” Circulation, vol. 112, no. 9, supplement, pp. I377–I382, mechanical dyssynchrony,” Circulation, vol. 112, no. 7, pp. 992–
2005. 1000, 2005.
[12] S. Maréchaux, Z. Hachicha, A. Bellouin et al., “Usefulness of [27] O. I. I. Soliman, M. L. Geleijnse, D. A. M. J. Theuns et al.,
exercise-stress echocardiography for risk stratification of true “Usefulness of left ventricular systolic dyssynchrony by real-
asymptomatic patients with aortic valve stenosis,” European time three-dimensional echocardiography to predict long-term
Heart Journal, vol. 31, no. 11, pp. 1390–1397, 2010. response to cardiac resynchronization therapy,” The American
[13] P. Lancellotti, J. Magne, E. Donal et al., “Determinants and Journal of Cardiology, vol. 103, no. 11, pp. 1586–1591, 2009.
prognostic significance of exercise pulmonary hypertension in [28] A. V. Khaw, R. S. von Bardeleben, C. Strasser et al., “Direct mea-
asymptomatic severe aortic stenosis,” Circulation, vol. 126, no. 7, surement of left ventricular outflow tract by transthoracic real-
pp. 851–859, 2012. time 3D-echocardiography increases accuracy in assessment of
[14] J. Monin, J. Quéré, M. Monchi et al., “Low-gradient aortic steno- aortic valve stenosis,” International Journal of Cardiology, vol.
sis. Operative risk stratification and predictors for long-term 136, no. 1, pp. 64–71, 2009.
outcome: a multicenter study using dobutamine stress hemo- [29] L. Sugeng, S. K. Shernan, I. S. Salgo et al., “Live 3-dimensional
dynamics,” Circulation, vol. 108, no. 3, pp. 319–324, 2003. transesophageal echocardiography. Initial experience using the
[15] L. A. Piérard and P. Lancellotti, “The role of ischemic mitral fully-sampled matrix array probe,” Journal of the American Col-
regurgitation in the pathogenesis of acute pulmonary edema,” lege of Cardiology, vol. 52, no. 6, pp. 446–449, 2008.
The New England Journal of Medicine, vol. 351, no. 16, pp. 1627– [30] D. G. Gibson, T. A. Prewitt, and D. J. Brown, “Analysis of left
1634, 2004. ventricular wall movement during isovolumic relaxation and its
10 BioMed Research International

relation to coronary artery disease,” The British Heart Journal, [45] J. Kramer, M. Niemann, D. Liu et al., “Two-dimensional speckle
vol. 38, no. 10, pp. 1010–1019, 1976. tracking as a non-invasive tool for identification of myocardial
[31] P. Palka, A. Lange, A. D. Fleming, G. R. Sutherland, L. N. Feen, fibrosis in Fabry disease,” European Heart Journal, vol. 34, no. 21,
and W. N. McDicken, “Doppler tissue imaging: myocardial wall pp. 1587–1596, 2013.
motion velocities in normal subjects,” Journal of the American [46] J. L. Hare, J. K. Brown, R. Leano, C. Jenkins, N. Woodward,
Society of Echocardiography, vol. 8, no. 5, pp. 659–668, 1995. and T. H. Marwick, “Use of myocardial deformation imaging to
[32] S. R. Ommen, R. A. Nishimura, C. P. Appleton et al., “Clin- detect preclinical myocardial dysfunction before conventional
ical utility of Doppler echocardiography and tissue Doppler measures in patients undergoing breast cancer treatment with
imaging in the estimation of left ventricular filling pressures: a trastuzumab,” The American Heart Journal, vol. 158, no. 2, pp.
comparative simultaneous Doppler-catheterization study,” Cir- 294–301, 2009.
culation, vol. 102, no. 15, pp. 1788–1794, 2000. [47] M. J. Stewart, “Contrast echocardiography,” Heart, vol. 89, no. 3,
[33] H. Blessberger and T. Binder, “Two dimensional speckle track- pp. 342–348, 2003.
ing echocardiography: basic principles,” Heart, vol. 96, no. 9, pp. [48] R. Janardhanan, G. Dwivedi, S. Hayat, and R. Senior, “Myocar-
716–722, 2010. dial contrast echocardiography: a new tool for assessment of
[34] J. Gorcsan III and H. Tanaka, “Echocardiographic assessment myocardial perfusion,” Indian Heart Journal, vol. 57, no. 3, pp.
of myocardial strain,” Journal of the American College of Cardi- 210–216, 2005.
ology, vol. 58, no. 14, pp. 1401–1413, 2011.
[49] S. B. Feinstein, F. J. T. Cate, W. Zwehl et al., “Two-dimensional
[35] T. H. Marwick, R. L. Leano, J. Brown et al., “Myocardial strain contrast echocardiography. I. In vitro development and quanti-
measurement with 2-dimensional speckle-tracking echocardi- tative analysis of echo contrast agents,” Journal of the American
ography. Definition of normal range,” JACC: Cardiovascular College of Cardiology, vol. 3, no. 1, pp. 14–20, 1984.
Imaging, vol. 2, no. 1, pp. 80–84, 2009.
[50] R. Hoffmann, S. von Bardeleben, F. T. Cate et al., “Assessment
[36] A. C. T. Ng, M. Sitges, P. N. Pham et al., “Incremental of systolic left ventricular function: a multi-centre comparison
value of 2-dimensional speckle tracking strain imaging to wall of cineventriculography, cardiac magnetic resonance imaging,
motion analysis for detection of coronary artery disease in unenhanced and contrast-enhanced echocardiography,” Euro-
patients undergoing dobutamine stress echocardiography,” The pean Heart Journal, vol. 26, no. 6, pp. 607–616, 2005.
American Heart Journal, vol. 158, no. 5, pp. 836–844, 2009.
[51] R. Hoffmann, S. von Bardeleben, J. D. Kasprzak et al., “Analysis
[37] C. B. Ingul, E. Rozis, S. A. Slordahl, and T. H. Marwick, “Incre-
of regional left ventricular function by cineventriculography,
mental value of strain rate imaging to wall motion analysis
cardiac magnetic resonance imaging, and unenhanced and
for prediction of outcome in patients undergoing dobutamine
contrast-enhanced echocardiography: a multicenter compari-
stress echocardiography,” Circulation, vol. 115, no. 10, pp. 1252–
son of methods,” Journal of the American College of Cardiology,
1259, 2007.
vol. 47, no. 1, pp. 121–128, 2006.
[38] R. Hoffmann, E. Altiok, B. Nowak et al., “Strain rate measure-
ment by Doppler echocardiography allows improved assess- [52] W. G. Hundley, A. M. Kizilbash, I. Afridi, F. Franco, R. M.
ment of myocardial viability in patients with depressed left ven- Peshock, and P. A. Grayburn, “Administration of an intravenous
tricular function,” Journal of the American College of Cardiology, perfluorocarbon contrast agent improves echocardiographic
vol. 39, no. 3, pp. 443–449, 2002. determination of left ventricular volumes and ejection fraction:
comparison with cine magnetic resonance imaging,” Journal of
[39] L. Hanekom, C. Jenkins, L. Jeffries et al., “Incremental value
the American College of Cardiology, vol. 32, no. 5, pp. 1426–1432,
of strain rate analysis as an adjunct to wall-motion scoring for
1998.
assessment of myocardial viability by dobutamine echocardio-
graphy: a follow-up study after revascularization,” Circulation, [53] S. Malm, S. Frigstad, E. Sagberg, H. Larsson, and T. Skjaerpe,
vol. 112, no. 25, pp. 3892–3900, 2005. “Accurate and reproducible measurement of left ventricular
volume and ejection fraction by contrast echocardiography: a
[40] H. Tanaka, H. Nesser, T. Buck et al., “Dyssynchrony by speckle-
comparison with magnetic resonance imaging,” Journal of the
tracking echocardiography and response to cardiac resynchro-
American College of Cardiology, vol. 44, no. 5, pp. 1030–1035,
nization therapy: results of the speckle tracking and resynchro-
2004.
nization (STAR) study,” European Heart Journal, vol. 31, no. 14,
pp. 1690–1700, 2010. [54] B. K. Koo, D. Choi, J. W. Ha, S. M. Kang, N. Chung, and S. Y.
[41] F. Z. Khan, M. S. Virdee, C. R. Palmer et al., “Targeted left Cho, “Isolated noncompaction of the ventricular myocardium:
ventricular lead placement to guide cardiac resynchronization contrast echocardiographic findings and review of the litera-
therapy: the TARGET study: a randomized, controlled trial,” ture,” Echocardiography, vol. 19, no. 2, pp. 153–156, 2002.
Journal of the American College of Cardiology, vol. 59, no. 17, pp. [55] P. Soman, J. Swinburn, M. Callister, N. G. Stephens, and R.
1509–1518, 2012. Senior, “Apical hypertrophic cardiomyopathy: bedside diagno-
[42] E. S. Chung, A. R. Leon, L. Tavazzi et al., “Results of the predic- sis by intravenous contrast echocardiography,” Journal of the
tors of response to CRT (PROSPECT) trial,” Circulation, vol. 117, American Society of Echocardiography, vol. 14, no. 4, pp. 311–313,
no. 20, pp. 2608–2616, 2008. 2001.
[43] J. J. Bax and J. Gorcsan III, “Echocardiography and noninvasive [56] S. Thanigaraj, K. B. Schechtman, and J. E. Perez, “Improved
imaging in cardiac resynchronization therapy. Results of the echocardiographic delineation of left ventricular thrombus
PROSPECT (predictors of response to cardiac resynchroniza- with the use of intravenous second-generation contrast image
tion therapy) study in perspective,” Journal of the American Col- enhancement,” Journal of the American Society of Echocardiog-
lege of Cardiology, vol. 53, no. 21, pp. 1933–1943, 2009. raphy, vol. 12, no. 12, pp. 1022–1026, 1999.
[44] B. N. Shah, M. de Villa, R. S. Khattar, and R. Senior, “Imaging [57] S. Thanigaraj, R. F. Nease Jr., K. B. Schechtman, R. L. Wade, S.
cardiac sarcoidosis: the incremental benefit of speckle tracking Loslo, and J. E. Pérez, “Use of contrast for image enhancement
echocardiography,” Echocardiography, 2013. during stress echocardiography is cost-effective and reduces
BioMed Research International 11

additional diagnostic testing,” The American Journal of Cardi-

ology, vol. 87, no. 12, pp. 1430–1432, 2001.
[58] S. Kaul and A. R. Jayaweera, “Coronary and myocardial blood
volumes: noninvasive tools to assess the coronary microcircu-
lation?” Circulation, vol. 96, no. 3, pp. 719–724, 1997.
[59] K. Wei, A. R. Jayaweera, S. Firoozan, A. Linka, D. M. Skyba,
and S. Kaul, “Basis for detection of stenosis using venous
administration of microbubbles during myocardial contrast
echocardiography: bolus or continuous infusion?” Journal of the
Ameri-can College of Cardiology, vol. 32, no. 1, pp. 252–260, 1998.
[60] W. F. Armstrong, T. M. Mueller, E. L. Kinney, E. G. Tickner, J.
C. Dillon, and H. Feigenbaum, “Assessment of myocardial per-
fusion abnormalities with contrast-enhanced two-dimensional
echocardiography,” Circulation, vol. 66, no. 1, pp. 166–173, 1982.
[61] C. Tei, T. Sakamaki, P. M. Shah et al., “Myocardial contrast echo-
cardiography: a reproducible technique of myocardial opacifi-
cation for identifying regional perfusion deficits,” Circulation,
vol. 67, no. 3, pp. 585–593, 1983.
[62] R. Senior, H. Becher, M. Monaghan et al., “Contrast echocardio-
graphy: evidence-based recommendations by european associ-
ation of echocardiography,” European Journal of Echocardiogra-
phy, vol. 10, no. 2, pp. 194–212, 2009.
[63] S. Bhattacharyya, R. Khattar, and R. Senior, “Characterisation of
intra-cardiac masses by myocardial contrast echocardiography,”
International Journal of Cardiology, vol. 163, no. 1, pp. e11–e13,
2013.
[64] L. A. Smith, R. Dworakowski, A. Bhan et al., “Real-time three-
dimensional transesophageal echocardiography adds value to
transcatheter aortic valve implantation,” Journal of the American
Society of Echocardiography, vol. 26, no. 4, pp. 359–369, 2013.
[65] F. Regoli, F. F. Faletra, G. Nucifora et al., “Feasibility and acute
efficacy of radiofrequency ablation of cavotricuspid isthmus-
dependent atrial flutter guided by real-time 3D TEE,” JACC:
Cardiovascular Imaging, vol. 4, no. 7, pp. 716–726, 2011.
[66] S. S. Kim, Z. M. Hijazi, R. M. Lang, and B. P. Knight, “The use of
intracardiac echocardiography and other intracardiac imaging
tools to guide noncoronary cardiac interventions,” Journal of the
American College of Cardiology, vol. 53, no. 23, pp. 2117–2128,
2009.
[67] J. M. Mangrum, J. P. Mounsey, L. C. Kok, J. P. DiMarco, and D. E.
Haines, “Intracardiac echocardiography-guided, anatomically
based radiofrequency ablation of focal atrial fibrillation origi-
nating from pulmonary veins,” Journal of the American College
of Cardiology, vol. 39, no. 12, pp. 1964–1972, 2002.
[68] R. Bala, J. F. Ren, M. D. Hutchinson et al., “Assessing epicardial
substrate using intracardiac echocardiography during VT abla-
tion,” Circulation: Arrhythmia and Electrophysiology, vol. 4, no.
5, pp. 667–673, 2011.
[69] C. Vigna, N. Marchese, M. Zanchetta et al., “Echocardio-
graphic guidance of percutaneous patent foramen ovale closure:
head-to-head comparison of transesophageal versus rotational
intracardiac echocardiography,” Echocardiography, vol. 29, no.
9, pp. 1103–1110, 2012.
[70] T. Bartel, N. Bonaros, L. Müller et al., “Intracardiac echocar-
diography: a new guiding tool for transcatheter aortic valve
replacement,” Journal of the American Society of Echocardiog-
raphy, vol. 24, no. 9, pp. 966–975, 2011.
[71] R. Bai, L. Di Biase, P. Mohanty et al., “Positioning of left ventric-
ular pacing lead guided by intracardiac echocardiography with
vector velocity imaging during cardiac resynchronization ther-
apy procedure,” Journal of Cardiovascular Electrophysiology, vol.
22, no. 9, pp. 1034–1041, 2011.