Authors

• Jadranka Separovic Hanzevacki — Working Group on Echocardiography and Cardiac Imaging Modalities, Croatian Cardiac Society, Croatia — ORCID: 0000-0002-3437-6407

DOI

Full Text

Due to many technological and scientific discoveries, echocardiography has developed into a complex diagnostic examination with a detailed protocol that uses numerous highly complex and demanding analyses and calculations (1). The development of echocardiographic methods and heart imaging in general has allowed better, faster, and more rational diagnosis and treatment of patients with cardiac problems. It is almost impossible to describe the complexities of this examination in the framework that dates back to 1992 and has never been expanded with a single procedure and method since then, despite the fact that the recommendations and guidelines of echocardiography have undergone several changes in the meantime and new modern methods have been developed (2, 3). To illustrate this, even the term used for this examination is outdated in the list of diagnostic and therapeutic procedures of the Croatian Institute of Public Health (4): “Echocardiography with Doppler echocardiography” is far behind the times, and should be changed to “Standard transthoracic echocardiography” which is the term used in professional circles both in Croatia and abroad. Along with basic hemodynamics, an ultrasound examination of the heart assessing the function and blood flow of the heart necessarily uses Doppler echocardiography (including continuous wave Doppler, pulsed Doppler, and color flow imaging) and is not complete without it (5). Assessing heart valve disease, myocardial function and hereditary diseases of the heart and surrounding structures, congenital heart diseases must include all the standard methods: one- and two-dimensional imaging (necessary for structure analysis and precise measurement) and Doppler echocardiography. **The examination is not complete if any of these standard methods is omitted.** Thus, echocardiography includes the use of Doppler echocardiography by definition, and cannot be called echocardiography without it. A basic orientational “heart viewing” is sometimes performed to establish a few urgent diagnoses, but it does not include Doppler echocardiography and thus surely cannot be considered identical to standard transthoracic echocardiography. As technology and medicine developed, in particular due to advancements in cardiology and echocardiography, heart ultrasounds have changed completely in terms of their components and terminology, and new methods and tests have been developed that are now used routinely (e.g. Doppler myocardial imaging, three-dimensional echocardiography, speckle tracking, etc.). Due to advancements in echocardiography both in Croatia and abroad, this valuable and irreplaceable cardiologic examination should be evaluated based on international expert recommendations. Several categories of echocardiography must be differentiated, depending on the time, expertise, staff, and technical requirements, evaluating existing expenses appropriately. In diagnosing complex patients, very complex diagnostic methods must be used. These include hemodynamic measurements and advanced echocardiographic procedures, which are: Doppler myocardial imaging, stress echocardiography, 2D stain imaging, optimization of the electrostimulator, and three-dimensional echocardiography (3). These are complex echocardiographic procedures that require more time, high expertise and technical requirements, and complex analysis (even more so than magnetic resonance imaging, for instance), and must thus be considered individually. This is why the American Society of Echocardiography categorizes echocardiographic examinations based on their complexity (orientational, simple, and complex). Considering all the above, it is extremely important to **standardize the basic echocardiographic examination**. In line with the recommendations of the European Association of Cardiovascular Imaging (1) and the development of cardiac diagnostics, the Working Group on Echocardiography and Cardiac Imaging Modalities of the Croatian Cardiac Society supports the standardization of echocardiographic examination as the first step to achieving consistent high quality echocardiographic results and their practicable application. This includes applying appropriate guidelines and evaluating medical personnel, with the interests of the patients and the overarching goal. Standardization of modern echocardiography should include the following:- **Continuous electrocardiographic monitoring**. An electrocardiogram enables timing of the various parts of the heart cycle, which is crucial for accurate measurement. Without the electrocardiogram, structure imaging and Doppler parameters will be incorrect, and lead to improper interpretation of the results.- **Respiration monitoring** during echocardiography using electrodes on the thorax. According to the recommendations from echocardiographic societies (1), electrocardiography is not complete without an assessment of the influence of respiration on basic hemodynamic events in the heart. It is crucial to determine the level of urgency in some lethal states.- Every measurement and piece of data obtained during echocardiography must be **archived and readily available**. Electrocardiographic examinations should be archived in digital format according to the recommended protocols of the European and American echocardiography associations, which define the contents and quality of the archived data as well as the technical and physiological conditions, including all image and quantitative data (1). (The recommended protocol of the Working Group on Echocardiography and the European Association of Echocardiography prescribes the contents of the examination as well as the conditions, methods, and contents of the results).- **The expertise of a specialist/subspecialist in the subsequent analysis** of the images. Determining the hemodynamics in the set intervals of the heart cycle sets echocardiography apart from other sonographic methods and makes it a very complex procedure in which the knowledge and expertise of a specialist are vital, just as in magnetic resonance imaging of the heart, computed tomography, etc. The job of the specialist includes performing the measurements, calculating the physical parameters of the basic hemodynamics, digital reconstruction of the structures in question, volume parameters in all phases of the heart cycle, archiving the data on portable data carriers for the patient’s use, and directly writing down the results at the workstation. The additional time spent after the examination is at least 30 minutes, and can range to several hours in complex cases. (Included are measurement preparations and calculating complex numeric variables for quantifying valve defects, pathological compounds, and indicators of the functional abilities of the ventricle according to the recommendations of the European Association of Echocardiography.)- The minimal timeframe for a standardized echocardiographic examination must be 30-40 minutes; patient appointment intervals must not be shorter than that. According to the Croatian Health Insurance Fund’s current guidelines (4), the health insurance price of diagnostic procedures for outpatients is lower than the lowest prices for the same procedures in Eastern European countries, and several times lower than other European countries, e.g. Great Britain, France, Sweden: (§100-150); Slovenia: (§70), Belgium (§70), Romania (§70). The price of echocardiography in Croatia is so low it **does not cover the costs** of all integral elements of modern echocardiography, and the work of physicians and echocardiography technicians is neglected. For instance, the costs of one-dimensional imaging or M-mode, excluded from the Croatian Institute of Public Health’s outline of the procedure in 2008, are not covered by the price. One-dimensional imaging is an integral part of the procedure and cannot be replaced with other types of imaging while adhering to expert rules and guidelines, so it is always used in echocardiographic examinations. Concerning two-dimensional imaging, the time and staff guidebook says that “Ö that method gives the same data as 1D echocardiography in two dimensions”. This emphasizes that the same structure is being shown in two dimensions, and does not imply that the data acquired using these two methods will be the same! This is because one-dimensional echocardiography has a temporal resolution (1000 Hz) which is not achievable using other methods, and is the only way to get accurate and adequately precise standard measurements as well as determine time intervals and morphological and dynamic analysis (6). In parallel with the advancement of echocardiography to completely new diagnostic levels and capabilities, the criteria of expertise for cardiologists performing the procedure have risen as well, due to the recommended accreditation of echocardiographic competence and skills at the national or European levels, which is a requirement for laboratory accreditation by the European Association of Echocardiography (7, 8). An additional challenge for the echocardiographic society is maintaining appropriate examination quality in the face of exponential growth of the (justified and unjustified) demand for echocardiographic examinations (9). **Medical priorities** must be considered in order to perform services in an acceptable timeframe with the goal of providing the best cardiologic care and avoiding serious health issues for the patients. In this way, the appropriate diagnostic procedures are performed in order to quickly and rationally establish a diagnosis despite the limited examination options and prohibitive costs. One of the possible ways to increase the maximum number of procedures that can be performed in the given circumstances is including other highly-educated professionals in the process of echocardiographic examination, in line with the examples of Great Britain and the USA; a high level of expertise in the management of technological and human resources incorporates a hierarchy system among the staff performing the procedure. Thus, the part of the procedure related to standardized protocol archiving can be performed by a highly educated echocardiographic technician while the cardiologist focuses on difficult measurements, reconstruction, diagnosis, and analysis. ## Acknowledgments Figures on cover by courtesy of Echocardiographic Laboratory University Hospital Centre Zagreb — Refferal Centre for Echocardiography, Croatian Ministry of Health; Mitral valve prolapse, Transesophageal echocardiography — multiplane, 3D and 3D Color Doppler reconstructions.

Literature

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