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Certification in Congenital Heart Disease Echocardiography

Syllabus

European Association of CardioVascular Imaging (EACVI))

Association for European Paediatric Cardiology (AEPC) Working Group on Grown-up Congenital Heart Disease of ESC (WG 22)

Introduction:

This syllabus is a guide for candidates wishing to pursue certification in congenital heart echocardiography. The candidate is expected to know and be skilled in basic principles of cardiac ultrasound. Additionally, they should know and understand the range of congenital heart defects in children and adults, and acquired heart defects in childhood. Although not all candidates will have the opportunity to train or work in cardiac surgical centres, they should be competent in the echocardiographic evaluation of unoperated congenital heart disease, the assessment of patients for surgical or catheter treatment, and post-procedural review. Intraoperative and cardiac catheter guidance for interventions is more advanced and the candidate is not expected to have experience of this, although an understanding of this is encouraged.

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Part I. General Concepts ..................................................................................................................................... 4

The clinical role of echocardiography and Doppler in paediatric and congenital heart disease ............................ 4

Service provision ...................................................................................................................................................... 4

Relationship with patients ....................................................................................................................................... 4

Conscious sedation in children ................................................................................................................................ 4

Reporting and documentation of paediatric and congenital studies ...................................................................... 4

Safety of ultrasound ................................................................................................................................................ 4

Part II. Imaging physics & instrumentation in paediatric and congenital echocardiography .. 5

Concepts and terminology of cardiac ultrasound ................................................................................................... 5

Propagation of ultrasound through tissues ............................................................................................................. 5

Ultrasound Transducers .......................................................................................................................................... 5

Imaging physics ....................................................................................................................................................... 5

Echo Instrumentation .............................................................................................................................................. 5

Optimising Images ................................................................................................................................................... 6

Part III. Doppler physics & fluid dynamics in paediatric and congenital ......................................... 6

echocardiography ................................................................................................................................................ 6

Basic Fluid Dynamics ............................................................................................................................................... 6

Basic Principles of Doppler ...................................................................................................................................... 6

Spectral Doppler ...................................................................................................................................................... 6

Colour Flow Instrumentation ................................................................................................................................... 7

Measurements and calculations ............................................................................................................................. 7

Tissue Doppler Imaging (TDI) and Deformation ...................................................................................................... 7

Part IV. Cardiac anatomy and physiology for paediatric and adult congenital

echocardiography anatomy of the thorax ................................................................................................... 8

General thoracic anatomy ....................................................................................................................................... 8

General concepts of cardiac morphology and echo identification .......................................................................... 8

Terminology of congenital heart disease ................................................................................................................ 9

The cardiac cycle ..................................................................................................................................................... 9

Fetal and neonatal physiology ................................................................................................................................ 9

The physiology of congenital heart disease ............................................................................................................ 9

Part V. The different congenital heart defects and treatment for the paediatric and

congenital echocardiographer ..................................................................................................................... 10

A) Septation defects .................................................................................................................................................. 10

Ventricular septal defect (VSD) ............................................................................................................................. 10

Atrial septal defect (ASD) ...................................................................................................................................... 10

Atrioventricular septal defect (AVSD).................................................................................................................... 10

B. Shunt lesions not caused by septation defects ..................................................................................................... 10

Arterial duct ........................................................................................................................................................... 10

Partial anomalous pulmonary venous drainage (PAPVD) ..................................................................................... 11

Basic anatomy and echocardiographic features of other acyanotic shunts ......................................................... 11

C. Cyanotic congenital heart defects......................................................................................................................... 11

Ventriculoarterial discordance (transposition of the great arteries) .................................................................... 11

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Tetralogy of Fallot (TOF)/pulmonary atresia with ventricular septal defect (PA/VSD) ............................................. 11

Pulmonary atresia with intact septum (PA/IVS) .................................................................................................... 11

Total anomalous pulmonary venous drainage (TAPVD) ....................................................................................... 12

D. Other complex lesions .......................................................................................................................................... 12

Common arterial trunk (CAT) ................................................................................................................................ 12

Lesions with single ventricle physiology ................................................................................................................ 12

Atrioventricular and ventriculoarterial discordance (AV/VA discordance) ........................................................... 13

Double outlet right ventricle (DORV) ..................................................................................................................... 13

E. Congenital valve disease ....................................................................................................................................... 13

The mitral valve ..................................................................................................................................................... 13

The aortic valve ..................................................................................................................................................... 13

The pulmonary valve ............................................................................................................................................. 14

The tricuspid valve (including Ebstein’s Malformation) ........................................................................................ 14

Prosthetic Valves ................................................................................................................................................... 14

F. Left outflow obstruction ........................................................................................................................................ 15

Subvalvular/supravalvar aortic stenosis ............................................................................................................... 15

Coarctation of the aorta ........................................................................................................................................ 15

Interrupted aortic arch .......................................................................................................................................... 15

G. Right outflow obstruction ..................................................................................................................................... 15

Subvalvular/supravalvar stenosis/peripheral branch stenosis.............................................................................. 15

H. Congenital coronary anomalies ............................................................................................................................ 16

Anomalous origin of the left coronary artery ........................................................................................................ 16

Coronary fistulae ................................................................................................................................................... 16

I. Miscellaneous lesions ............................................................................................................................................. 16

Cortriatriatum dexter and sinister ......................................................................................................................... 16

Intracardiac Masses .............................................................................................................................................. 16

Diseases of the aorta ............................................................................................................................................. 16

Pericardial Disease ................................................................................................................................................ 16

Part VI. Acquired heart disease in paediatrics and congenital heart disease ............................. 17

Kawasaki disease................................................................................................................................................... 17

Infective Endocarditis ............................................................................................................................................ 17

Rheumatic fever .................................................................................................................................................... 17

Intravascular thrombosis....................................................................................................................................... 17

Part VII. Cardiac functional evaluation in paediatric and adult congenital heart disease ...... 17

A. Ventricular Function ............................................................................................................................................. 17

Calculations ........................................................................................................................................................... 17

Diastolic function ................................................................................................................................................... 17

B. Pulmonary hypertension ....................................................................................................................................... 18

Pulmonary Hypertension ....................................................................................................................................... 18

C. Conditions associated with ventricular dysfunction ............................................................................................. 18

Dilated Cardiomyopathy ....................................................................................................................................... 18

Hypertrophic Cardiomyopathy .............................................................................................................................. 18

Restrictive Cardiomyopathy .................................................................................................................................. 18

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PART I. GENERAL CONCEPTS The clinical role of echocardiography and Doppler in paediatric and congenital heart disease

Indications for echocardiography

Information that echocardiography can and cannot provide

‘Ruling out’ pathology (sensitivity, specificity & Baye’s theorem)

Likelihood of findings influencing patient management

Role of multimodality imaging: o Cardiac catheterisation o Multislice CT scan o Magnetic resonance imaging o Nuclear Cardiology

Service provision

Advantages and disadvantages of physiologist-led versus physician-led service

Specific requirements for paediatric and congenital echocardiography laboratories

Provision and indication for specialised techniques, e.g. Transoesphageal echocardiography

Availability and access

Controlling workload

Training & motivation of staff

Audit, Quality Control, Clinical Governance Relationship with patients

Explaining the procedure in terms relevant to the patient/parents

Respect for patients’ dignity and cultural backgrounds

Relationships with patient, parents and colleagues

Handling requests for information about the study findings Conscious sedation in children

Explaining the procedure in terms relevant to the patient/parents

Specific environment for performing studies in children/adults with CHD

Indications for conscious sedation

Precautions, dosage, follow-up Reporting and documentation of paediatric and congenital studies

Standard methods and terminology used for describing congenital heart disease (segmental sequential analysis)

Distinction between technical and clinical reports

Responsibility for reporting

Medico-legal considerations (Data Protection Act) Safety of ultrasound

Potential hazardous biological effects o Heating, resonance and cavitation effects

Measurement of beam intensity (Spatial Peak Temporal Average, [SPTA])

Practical precautions: power levels, use of colour and continuous wave Doppler

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PART II. IMAGING PHYSICS & INSTRUMENTATION IN PAEDIATRIC AND CONGENITAL

ECHOCARDIOGRAPHY Concepts and terminology of cardiac ultrasound

Concept of compression waves

Definitions: frequency, wavelength, propagation velocity

Units of measurement: Hz and MHz, Decibel

Comparison of Ultrasound with audible sound Propagation of ultrasound through tissues

Speed of sound in different body tissues

Frequency range used for diagnostic imaging in children and adults with CHD

Distinction between specular reflection and backscatter

Principles of attenuation and scattering Ultrasound Transducers

Piezo-electric effect

General concepts of transducer construction

Characteristics of the ultrasound beam: o Near (Fresnel) & Far (Fraunhofer) zones, side lobes

Beam steering methods: mechanical & electronic

Focusing methods, including multiple transmit focusing Imaging physics

Factors affecting choice of imaging frequency: o Typical practical values for adults & children

Measurement and optimisation of resolution: axial, azimuthal and elevation

Broad-band imaging

Harmonic imaging

B mode and M Mode methods

Scanning speed limitations, relationships between pulse repetition frequency, frame rate, lines per frame, field of view, depth to be imaged.

Concept of Parallel Processing and its influence on frame rate and image quality

Effect on evaluation of rapid motion, temporal resolution

Grey scale and dynamic range

Lateral resolution and grating artefacts

Reverberation artefacts

Limiting factors for detecting small targets Echo Instrumentation

Function of machine controls: o Transmit power; overall gain; time gain compensation; reject, logarithmic

compression

Signal processing, dynamic range, pre-processing, post processing

Optimisation of imaging parameters including: o Transducer frequency, scan angle, gamma correction, spatial and temporal

smoothing

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Optimising Images

Use of gel

Positioning of the subject

Standard views: o Parasternal, apical (4, 5 and 2-chamber), subcostal, suprasternal, right parasternal,

long and short axis

Use of non-standard views

Adapting for subjects with difficult windows

PART III. DOPPLER PHYSICS & FLUID DYNAMICS IN PAEDIATRIC AND CONGENITAL ECHOCARDIOGRAPHY Basic Fluid Dynamics

Fluid flow: significance of peak and mean velocities

Determination of volumetric flow

Continuity equation

Laminar & turbulent flow: Reynolds’ equation (qualitative)

Transition from Laminar to turbulent flow: inlet jet

Bernoulli equation Basic Principles of Doppler

Interaction of ultrasound waves with moving blood: the Doppler effect

The Doppler equation: factors influencing magnitude of Doppler shift

Spectral analysis: fast Fourier transform (qualitative)

The spectral Doppler display: determination of mean, modal and peak velocities

Limitation of CW Doppler caused by lack of depth discrimination

The effect of beam angle errors on Doppler velocities

Aliasing: o How it is caused and how it manifests in practice: the Nyquist limit o Influence on aliasing of: transducer frequency; sample depth (range x velocity

product); and beam angle

High pulse repetition frequency (extended range) PW Doppler

Relative advantages and disadvantages of CW, PW and HPRF modes

Concept of colour flow imaging as multi-sampled PW

Velocity estimation, by moving target indication and autocorrelation (qualitative)

Limitations of mean velocity: use of velocity variance to show high velocities/turbulence

Aliasing in colour Doppler

Packet size, colour mode and sector size and their effect on frame rate and aliasing

Spectral Doppler

Duplex Doppler using imaging transducers

The ‘stand-alone’ Doppler probe (pencil probe)

Features of the spectral display: positive & negative velocities; scale & baseline controls.

Effect of high- and low-pass filter and intensity threshold (‘reject’) settings

Pulsed Doppler sample volume: influence of gate length and distance (beam width)

Representation of signal strength by image intensity

How aliasing manifests on the spectral display

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Colour Flow Instrumentation

The colour display: Blue-Away, Red-Towards (BART) convention

Colour maps to show velocity scales

Image domination and additive colour modes

Basic principles of Tissue Doppler Imaging, including optimisation of filters for detecting tissue versus blood velocities

Difference between velocity and power (signal amplitude) displays Measurements and calculations

On-screen measurement of length, slope, area, volume and time interval, and their significance for 2-D images, M-mode and spectral Doppler displays

Standard M-mode measurements and calculations o Shortening Fraction o TAPSE o Wall thickness

Limitations of measurements and/or calculations

Peak and Mean pressure gradient measurements by Doppler and their relationship to catheterisation data

Tissue Doppler Imaging (TDI) and Deformation

Understand principles of TDI

Identify a’, e’ s’ on PW-TDI

Limitations of measurements and/or calculations

Understand age.size related differences in TDI measurements

Understand concept of Displacement imaging ▪ Strain and strain rate

Definition

Direction of deformation

Speckle Tracking Echocardiography

Principles

Physical origin of speckles

Tracking of speckle motion

Clinical applications

Haemodynamic assessment -Assessment of filling pressures

Systolic (global and regional) function / Diastolic function

Detection of subclinical myocardial dysfunction

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PART IV. CARDIAC ANATOMY AND PHYSIOLOGY FOR PAEDIATRIC AND ADULT

CONGENITAL ECHOCARDIOGRAPHY ANATOMY OF THE THORAX General thoracic anatomy

Thorax contained by rib cage & diaphragm

Lungs & pleura

Heart & pericardium

Mediastinum

Blood vessels within the thorax General concepts of cardiac morphology and echo identification

Atrial situs: o Definition, abdominal aorta and great vein relationship

Systemic venous return: morphology

Pulmonary venous return: morphology

Atrial anatomy: o Difference between right and left atrium, atrial appendages

Ventricular anatomy: o Morphology of right and left ventricle o Atrioventricular valve arrangement o Trabecular pattern o Ventricular shape o Right-handed vs. left handed ventricular configuration o Inlet and outlet valve relationships o Chordal attachments

Atrioventricular valves: anatomy of mitral and tricuspid valve

Semilunar valves: anatomy of pulmonary and aortic valve

The inter-atrial septum: o Morphology o Primum and secundum septum o Foramen ovale o Sinus venosus

The interventricular septum: o Morphology o Inlet septum o Outlet septum o Membranous septum o Trabecular

Pulmonary artery anatomy

Aortic anatomy

Coronary artery anatomy: normal anatomy and variants

The arterial duct: normal anatomy and normal variants

The pericardium: anatomy

Visualisation of normal cardiac anatomy and normal variants in standard echocardiography planes

Normal valve function, normal Doppler parameters and normal variants

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Terminology of congenital heart disease

Atrial situs and situs abnormalities: o Situs inversus o Right and left isomerism

Atrioventricular connections: o Concordant o Discordant o Double inlet o Absent connection o Straddling valves o Criss-cross connections

‘Univentricular’ heart: description of different variants

Ventriculoarterial connections: o Concordant, o Discordant o Single outlet o Double outlet

Great artery relationships The cardiac cycle

Temporal relationships of the ECG, chamber pressures and valve movements

Typical values for intracardiac pressures

Relationship of valve movements to heart sounds Fetal and neonatal physiology

The fetal circulation: how it differs from the postnatal circulation

Circulatory changes at birth: the neonatal circulation

Adaptations in circulatory physiology during the first weeks of life The physiology of congenital heart disease

Causes of chamber dilation and hypertrophy

Ventricular pressure and volume overload

Physiological effect of shunts at atrial, ventricular and great artery level

Physiological effect of regurgitation through all four valves

Physiological effect of stenosis on all four valves

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PART V. THE DIFFERENT CONGENITAL HEART DEFECTS AND TREATMENT FOR THE

PAEDIATRIC AND CONGENITAL ECHOCARDIOGRAPHER A) Septation defects Ventricular septal defect (VSD)

Assessment of unoperated VSD: o Location and size o M-mode and 2D features o Assessment of shunt size and pulmonary pressure o Anterior or posterior malalignment

Associated features: o Aortic valve cusp prolapse o Discrete subvalvular aortic stenosis o Double chambered right ventricle

Echocardiographic assessment of surgical treatment for VSD: o Post-operative complications: e.g. residual defects, sub-aortic stenosis

Echocardiographic assessment of percutaneous treatment for different types of VSD. Atrial septal defect (ASD)

Assessment of unoperated ASD: o Secundum, primum and sinus venosus defects o Location and size o M-mode and 2D echo features o Assessment of shunt size o Common associated lesions

Other causes of right ventricular volume overload

Echocardiographic assessment of surgical treatment of different types of ASD

Echocardiographic assessment of percutaneous treatment of ASD. Atrioventricular septal defect (AVSD)

Assessment of unoperated AVSD: o Size of atrial and ventricular components o Atrioventricular valve function o Ventricular imbalance o Assessment of pulmonary pressure

Echocardiographic assessment of post-operative AVSD: o Atrioventricular valve function o Sub-aortic stenosis o Residual defects

B. Shunt lesions not caused by septation defects Arterial duct

Assessment of patent arterial duct o Imaging planes for isolated duct o Assessment of shunt size o Ductal flow patterns and pulmonary artery pressure

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o

Anatomical variations with different cardiac defects

Other defects causing shunt at great artery level

Echocardiographic assessment of surgical and percutaneous treatment for patent arterial duct

Partial anomalous pulmonary venous drainage (PAPVD)

Assessment of partial anomalous pulmonary venous drainage o Anatomy – which veins drain where o Associated defects o Haemodynamic effect

Echocardiographic assessment of surgical treatment for PAPVD Basic anatomy and echocardiographic features of other acyanotic shunts

Aortopulmonary window

Unroofed coronary sinus

Origin of one pulmonary artery from aorta

Sinus of Valsalva fistula C. Cyanotic congenital heart defects Ventriculoarterial discordance (transposition of the great arteries)

Assessment of unrepaired ventriculoarterial discordance: o Anatomy o Coronary artery anatomy o Associated features: VSD, pulmonary stenosis, coarctation

Echocardiographic assessment of surgical treatment for ventriculoarterial discordance o Atrial switch (Mustard, Senning) o Arterial switch o Rastelli procedure

Tetralogy of Fallot (TOF)/pulmonary atresia with ventricular septal defect (PA/VSD)

Assessment of unrepaired TOF/pulmonary atresia with VSD: o Anatomy o Assessment of VSD o Right ventricular outflow tract assessment o Coronary artery anatomy o Sources of pulmonary blood flow o Size of branch pulmonary arteries o Arch laterality

Echocardiographic assessment of surgical treatment for TOF/pulmonary atresia with VSD: o Palliations: arterial shunt, right ventricular outflow tract stent, arterial ductal stent,

pulmonary valve balloon o Valve sparingTransannular patch o Right ventricle to pulmonary artery conduit o Haemodynamic effect of residual stenosis or regurgitation

Pulmonary atresia with intact septum (PA/IVS)

Assessment of unrepaired PA/IVS o Anatomy

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o Pulmonary valve morphology o Coronary artery anatomy/fistulae/sinusoids o Right ventricular morphology

Echocardiographic assessment of percutaneous and surgical treatments for PA/IVS: o Arterial shunt, right ventricular outflow tract stent, arterial ductal stent, radiofrequency

perforation and pulmonary valve balloon Total anomalous pulmonary venous drainage (TAPVD)

Assessment of unrepaired TAPVD o Anatomy o Location: supracardiac, cardiac, infracardiac o Size of pulmonary veins o Associated features

Echocardiographic assessment of surgical treatment for TAPVD: o Patency of confluence o Pulmonary vein stenosis o Right heart pressures

D. Other complex lesions Common arterial trunk (CAT)

Assessment of unrepaired CAT: o Anatomy o Morphology and function of truncal valve o Size and position of VSD o Committal of truncal valve to ventricle o Origin of pulmonary arteries o Coronary artery origins o Associated defects

Echocardiographic assessment of surgical treatment for CAT: o Truncal valve stenosis/regurgitation o Pulmonary artery stenosis o Right ventricle to pulmonary artery conduit function

Lesions with single ventricle physiology

Different variants: double inlet ventricles, double outlet ventricles, hypoplastic/absent atrioventricular connections etc

Anatomy: o Morphology of ventricle o Source of pulmonary blood flow o Source of systemic blood flow o Atrioventricular and ventriculoarterial valve function

Echocardiographic evaluation after staged palliation for single ventricle physiology: o Pulmonary artery banding o Norwood procedure o Arterial shunt o Bidirectional Glenn/hemi-Fontan o Fontan/total cavopulmonary connection (TCPC)

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Echocardiographic evaluation of the Fontan/(TCPC): o Types of Fontan/TCPC (atriopulmonary, lateral tunnel, extracardiac conduit) o Obstructions to the Fontan tunnel o Thromboses o Single ventricle function o Fenestration flow

Atrioventricular and ventriculoarterial discordance (AV/VA discordance)

Assessment of unrepaired AV/VA discordance: o Ventricular morphology o Associated defects

Echocardiographic follow-up of the unoperated patient: o Function of the systemic right ventricle and tricuspid valve

Echocardiographic follow-up of the operated patient: o Double switch (atrial and arterial switch)

Double outlet right ventricle (DORV)

Assessment of the unoperated patient with DORV: o Arrangement of the great vessels (and the relevant physiology) o Size and location of the VSD o Associated lesions

Echocardiographic assessment of the surgical treatment of DORV: o Residual VSD o Left or right ventricular outflow tract obstruction

E. Congenital valve disease The mitral valve

Assessment of the congenitally abnormal mitral valve: o Anatomy and different variants of mitral valve anomalies o Nomenclature for mitral valve leaflets o Description of the valve o Description of subvalvar apparatus o Measurement of orifice area by planimetry o Assessment of severity of stenosis/regurgitation

Doppler assessment of the mitral valve: o Mean and end-diastolic gradient o Area by ‘pressure half-time’: technique and limitations

Mitral valve prolapse: definition and echocardiographic aspects

Echocardiographic assessment of surgical mitral valve repair The aortic valve

Assessment of the congenitally abnormal aortic valve: o Morphology of the aortic valve o Number of leaflets o Assessment of the left ventricle: size, hypertrophy, systolic and diastolic function o Associated left ventricular outflow tract abnormalities o Effect on the aortic root o Assessment of severity of stenosis/regurgitation

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Doppler assessment of the aortic valve: o Peak and mean gradients o Apical, right parasternal and suprasternal positions o Continuity equation

Echocardiographic assessment of surgical and percutaneous treatments for congenital aortic valve disease

o Aortic valve balloon o Aortic valve repair o Aortic valve replacement o Ross procedure o Left ventricular remodelling

The pulmonary valve

Assessment of the congenitally abnormal pulmonary valve: o Morphology of the pulmonary valve o Number of leaflets o Assessment of the right ventricle: size, hypertrophy, systolic and diastolic function o Associated right ventricular outflow tract abnormalities o Assessment of severity of stenosis/regurgitation

Echocardiographic assessment of surgical and percutaneous treatments for congenital pulmonary valve disease

o Pulmonary valve balloon o Pulmonary valve repair o Pulmonary valve replacement o Right ventricular remodelling

The tricuspid valve (including Ebstein’s Malformation)

Assessment of the congenitally abnormal tricuspid valve: o Morphology of the tricuspid valve o Position of tricuspid valve annulus o Number of leaflets o Assessment of the right ventricle and right atrium: size, function o Associated abnormalities o Assessment of stenosis/regurgitation

Echocardiographic assessment of surgical and percutaneous treatments for congenital tricuspid valve disease

o Tricuspid valve repair o Cone repair

Prosthetic Valves

2D, M-Mode and Doppler features of the main types of replacement valves: o Ball & cage o Tilting Disc o Bi-leaflet o Stented Bioprostheses

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Age-related deterioration of bioprostheses

Understand role of TOE in examining normal and malfunctioning prosthetic valves

Prosthetic valve stenosis o Assessment by 2D, M-mode and Doppler o Normal ranges o Use of Continuity Equation for aortic prostheses

Prosthetic valve regurgitation o Trans-versus para-valvar regurgitation o Normal versus abnormal regurgitation

Assessment by CW, PW and Colour Doppler

Colour artefacts from mechanical prostheses F. Left outflow obstruction Subvalvular/supravalvar aortic stenosis

Anatomy and variants

Associated lesions

Echocardiographic assessment of severity

Evaluation of surgical treatment Coarctation of the aorta

Type of narrowing

Site of narrowing

Morphology and anatomy of the whole arch

Associated defects

Echocardiographic assessment: o Different echocardiographic appearances o Spectral Doppler appearances o Peak velocity and diastolic pattern o Relationship to measured gradient o Relationship to severity of obstruction

Effect of arterial duct on imaging and Doppler appearances

Echocardiographic assessment of percutaneous and surgical treatment of coarctation of the aorta:

o Recoarctation o Left ventricular remodelling

Interrupted aortic arch

Site of interruption

Associated lesions

Echocardiographic assessment of surgical treatment of interrupted aortic arch G. Right outflow obstruction Subvalvular/supravalvar stenosis/peripheral branch stenosis

Anatomy and variants

Associated lesions

Echocardiographic assessment of severity

Evaluation of surgical treatment

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H. Congenital coronary anomalies Anomalous origin of the left coronary artery

Origin of coronary arteries

Physiological effect

Assessment of surgical treatment for anomalous origin of the coronary artery Coronary fistulae

Origin of coronary arteries and drainage of fistulae

Physiological effect

Assessment of surgical treatment and percutaneous treatment for coronary fistulae I. Miscellaneous lesions Cortriatriatum dexter and sinister

Anatomy and echocardiographic appearance Intracardiac Masses

Typical locations for intracardiac tumours

Echocardiographic features intracardiac tumours

Differentiation of cardiac tumours

Features suggestive of malignancy

Understand role of TOE in assessment of intracardiac masses Diseases of the aorta

Technique for examining the ascending and descending thoracic aorta

Echocardiographic features of the normal aortic root, sinuses of Valsalva, ascending aorta and aortic arch

2-D, M-mode and Doppler features of: o Marfan’s syndrome o Sinus of Valsalva aneurysm

Pericardial Disease

Anatomy of the normal pericardium: o Relationships of serous pericardium to heart and great vessels o Transverse and oblique sinuses of the pericardium

Echocardiographic features of pericardial fluid o Location of fluid in relation to patient position and fluid volume o Differentiation from pleural effusion o Assessment of volume of pericardial fluid o Role of echocardiography in pericardiocentesis

Features of tamponade o Collapse of RA and/or RV walls o Effect on IVC o Effect on A-V valve flow velocities

Features of pericardial constriction o Effect on A-V valve flow velocities o Effect of respiration

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o SVC/hepatic vein flow o Differentiation from restrictive cardiomyopathy

PART VI. ACQUIRED HEART DISEASE IN PAEDIATRICS AND CONGENITAL HEART DISEASE Kawasaki disease

Common echocardiographic features

Echocardiographic follow-up Infective Endocarditis

Typical echocardiographic appearance of vegetations in bacterial and fungal endocarditis

Preferred locations for vegetations o ’Jet’ lesions o Congenitally abnormal structures o Hypertrophic cardiomyopathy

Complications: abscess, fistula, perforation

Understand role of TOE in suspected endocarditis

Echocardiographic follow-up Rheumatic fever

Common echocardiographic features

Evaluation of severity

Echocardiographic follow-up Intravascular thrombosis

Diagnostic echocardiographic criteria

Echocardiographic follow-up

PART VII. CARDIAC FUNCTIONAL EVALUATION IN PAEDIATRIC AND ADULT CONGENITAL

HEART DISEASE A. Ventricular Function Calculations

Derivation of Stroke Volume, Ejection Fraction and LV Mass

Methods of measuring LV volume, including biplane area, area-length and

Simpson’s rule methods

Echocardiographic calculation of cardiac output

Diastolic function

Methods of measuring diastolic dysfunction: E/A ratio, deceleration time, pulmonary venous flow patterns

Tissue Doppler derived E/e’

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B. Pulmonary hypertension Pulmonary Hypertension

2-D, M-mode and Doppler features of pulmonary hypertension

Causes of pulmonary hypertension: o Idiopathic o Related to congenital heart disease o Chronic pulmonary emboli o Secondary to lung diseases o Upper airway obstruction o Medication related

Measurement of pulmonary pressures from tricuspid and pulmonary regurgitant flow velocities

Assessment of inferior vena cava contraction C. Conditions associated with ventricular dysfunction Dilated Cardiomyopathy

2D, M-mode and Doppler features of dilated cardiomyopathy

Detection and assessment of associated lesions: functional valve regurgitation

Thrombus in cardiac chambers

Pericardial effusions

Associated abnormalities, e.g. mitral regurgitation

Role of echocardiography in assessment and follow-up Hypertrophic Cardiomyopathy

2D, M-mode and Doppler features of hypertrophic cardiomyopathy

Differentiation from other causes of hypertrophy, e.g. ‘athletic heart’

Techniques for measurement of left ventricular wall thickness, detection of intracavity flow acceleration

Assessment of right ventricular involvement

Associated abnormalities, e.g. mitral regurgitation

Role of echocardiography in assessment and follow-up Restrictive Cardiomyopathy

2D, M-mode and Doppler features of restrictive cardiomyopathy

Differentiation from pericardial constriction

Techniques for measurement of diastolic dysfunction

Associated abnormalities, e.g. mitral regurgitation

Role of echocardiography in assessment and follow-up