Udruženje kardiologa Srbije SRB ENG

Dnevni Izveštaj 01.03.2015. - dr Ivana Jovanović

dr Ivana Jovanović

Dear Colleagues,

I am delighted to share with You the first officially reviewed highlights of cardiovascular Imaging of Serbia 2015 which is being held in Belgrade Crown Plaza Hotel, March 1-3, 2015. If one can judge only by the first day, this certainly promises to be one of the most visited congresses that was ever held in Serbia, as well as the one with the broadestinternational attendance.

The lectures selected represent the most compelling topics of relevance to a broad array of clinical practitioners. One of the leading conceptual ideas of this congress is to emphasize how multimodality imaging has changed the practice of cardiology regarding disease diagnosing and monitoring. Morning started with a teaching session were prof M. Petrovic delivered some thoughts on an always interesting topic- Assessment of diastolic function.

The spot light topics of this day were presented during the Main session - the importance of multimodality imaging in Infective Endokarditis (IE). Unfortunately there is a outburst of this pathologic entity nowdays in Serbia. Prof. G Habib discussed multimodality imaging in infective endocarditis explaining the role of Echocardiography, nuclear imaging, ways of visualizing embolic complications. He stressed that Echo is not 100% sensitive (vegetation < 2mm, non vegetant IE, prosthetic and pace maker IE, vegetations not present or already embolized, MV prolapse with thickened valves). He emphasized the role of what emerged as a powerful imaging tool - 18FDG-PET-CT in early diagnosis of aortic abscess in Bioprosthetic valve (L. Saby et al Circ 2012.).

In comparison to Duke criteria (sensitivity 70%), addition of 18FDG-PET-CT raises the sensitivity level for detecting IE to 97% (p=0.008) (Saby L, Thuny F, Habib G.JACC 2013;11;61:2374-82). He highlighted Advantages of PET-CTY over echo telling that echo provides morphological imaging without accurate information on the activity of IE = insensitive for very early diagnosis; while PET/CT provides a functional imaging of inflammation and has the potential to bring an earlier diagnosis of IE (principle of FDG uptake by the metabolically active tissue/prosthesis). Importance of 18FDG-PET-CT in IE: early Dg and detection of secondary lesions. Concerning the embolic events in IE he discussed the role of CT scan in detecting of the embolic sites (ie splenic embolism). Echocardiography does play a key role, yet Dg is sometimes difficult where we should relay on prognostic assessment (hemodynamic risk, infectious and embolic risk) and not to forget the role of other imaging techniques like CT scan, MRI, PET. In his closing words he mentioned the project: Infective Endocarditis European Registry (EURO-ENDO) whose main objectives are 1) to evaluate the prognosis of patients with IE in Europe 2) to describe use of different imaging modalities in IE in Europe.

Prof B.Obrenovic drew out attention on how MRI or CT of the spine should be performed in IE pts. with back pain. Echocardiography should be done in pts. with DG of pyogenic spondilodiscitis and underlying cardiac conditions predisposing to IE (30.8% out of these pts develop IE, and they need prolonged AB therapy).

Prof B. Vujisic-Tesic emphasized that Duke criteria are less useful when it comes to PV and/or other cardiac devices. While blood cultures and echocardiography (where TEE is mandatory) still remain the cornerstones for diagnosis of IE, other imaging modalities like cardiac CT, PET/CT,cerebral MR imaging should also be a part of this complex diagnostic algorithm. Prof B. Vujisic-Tesic also talked us through some very interesting examples on this matter.

Prof B. Ivanovic gave an outstanding lecture where she talked abou the usefulness of real-time 3D echocardiography for diagnosis of IE, and since 2D TEE underestimates vegetation size, 3D-TEE should be used as a supplement for the analysis of vegetation size and morphology. Based on results of meta analysis -left sided vegetations bigger than 10 mm have a increased risk of systemic embolization and a need for valve replacement surgery (Ticher J Am Soc Echocardiogr 1997;10:562-8).

Today Prof G. Habib and Prof G. Sutherland were named Visiting Professors of the School of Medicine, University of Belgrade. During an opening ceremony of the congress Prof G. Sutherland held a memorial lecture Past, Present and Future of Deformation Imaging” in the honor of the late Prof Natalija Simin, a pioneer of echocardiography in Serbia. He gave an overview of the myocardial deformation imaging techniques development, paying special attention on the elementary concept of tissue Doppler imaging whose beginnings he was involved in. He highlighted the importance of LV longitudinal deformation and global longitudinal strain in that sense, which he believes is sensitive enough to detect subclinical forms of myocardial diseases. He also reminded us that strain rate correlates well with a “surrogate of LV contractility”- dP/dT, while strain correlates better with the ejection fraction (a ventricular volume change during cardiac cycle). Prof G. Sutherland discussed also 3D strain rate with high temporal resolution as a method who still needs to show it’s clinical importance in near future. He also gave a critical overview while talking about major limitation of deformation imaging-it’s load dependency (strain rate being less load dependent). On that note, his closing words were that the one who discovers quantification of left ventricular contractility that is load independent – will find an equivalent of the Holy Grail.

Prof G. Athanasopoulos discussed decision making concerning interventions for valve disease and the role of stress echo. He discussed the data from The Euro heart survey on valvular disease emphasizing the portion of pts with one of the valvular pathologies (aortic stenosis, aortic regurgitation or mitral regurgitation) who had an “over-use” or “under use” of the intervention. Prof G. Athanasopoulos reminded us that Stress echo in pts. with mitral stenosis may help distinguish pts who can benefit from surgery from those who could continue on medical treatment, as about it’s incremental value in predicting outcomes in pts. with asymptomatic aortic regurgitation. He reminded as on two still open issues- 1)selection of patients for mitral interventions; 2) transition from surgery to percutaneous mitral valve interventions . Critical reappraisal of the later is necessary before their widespread use.

Prof A. Salustri discussed necessary echo-doppler measurements after valve replacement (aortic, mitral) . He also focused on parameters needed for analyzing prosthesis-patient mismatch. Prof Salustri gave an comprehensive guidance of the course of such an examination. In the session that followed he represented a case of a young male (from the U.A.E.) with a rare inflammatory myofibroblastic tumor (with its first description in 1975) which is considered to be a low grade neoplasm.

Prof .B Obrenovic presented an article on a 30 year Single Center Experience in Atrial Myxomas (Thorac Cardiovasc Surg 2013;61:530-536).

It was very wise and practical to devote time to pulmonary embolism since most of us encounter that very often in our clinical practice. Prof Srbinovska talked about the role of echo as a method which helps in the initial risk stratification for PE especially in pts. with hypotension and shock, even though echo has a low sensibility to PE diagnosis. Its accuracy increases in pts. with massive PE. She concluded that negative echocardiography findings do not exclude PE but it can help in differential diagnosis for the acute chest pain syndrome.

Prof. G. Koraćević gave an outstanding lecture about the place of CT as the gold standard diagnostic tool for PE. He also talked about the role of D dimer and its age-adjustment in the diagnostic algorithm for PE. Up to 14% of pts could have a PE in spite of a negative D-dimer (Parikh N et al. Emerg Radiol.2015).

Prof D. Kalimanovska -Ostric delivered a comprehensive lecture on multimodality imaging in chronic pulmonary hypertension (PH). She introduced us with the place of chest radiography in diagnosis of PH, even though a normal chest X ray does not exclude PH. The role of echocardiography with all significant diagnostic parameters was presented in detail (determination of PASP, PVR, RV systolic function and parameters that help to determine it). Prof D. Kalimanovska presented an article about the prognostic value of intravascular OCT and its Ability for detecting PA fibrosis and its correlation with clinical prognosis. Patients. with severe fibrosis (≥22%) had more clinical events than pts. with less fibrosis (<22%). (DomingoE. The Open Respiratory Medicine Journal 2013:7;26-32. She mentioned right heart catheterization as a gold standard for confirming the diagnosis of PAH. In the future additional conventional angiography will be performed only if an adequate roadmap of pulmonary vasculature has not been provided by CT or CMR. She emphasized the significance of pulmonary angiography, chest CT, CT angiography and MRI and their complementary roles in diagnosis of PH and its causes.

Based on the significance of multimodality imaging previously presented, it was very interesting to end the today’s day with the Pitfalls in the interpretation! Five exquisite cases were presented – telling us about the need not to solely relay on one single diagnostic technique (even if it’s a case of a gold standard), yet to always use different imaging modalities – as a complement - since all of them can be a subject to a method limitation.

Looking forward to day No 2...Mean while..get some rest.. and sort Your impressions.

Best regards,
Ivana Jovanovic MD,
Department of echocardiography
Clinic for Cardiology
University Clinical Center of Serbia
26 Visegradska Street
11000 Belgrade