Stress Echocardiography Review for ACUSON Redwood™ Ultrasound System

Welcome to the Stress Echocardiography Review for the ACUSON Redwood™ Ultrasound System. This course is a high-level review of exercise and pharmacologic echocardiography. We will explore the six configurable stress protocols available on the ACUSON Redwood and examine how stages can be built, and views added as clinically indicated. Upon successful completion of this course, you will be able to: Understand the basic physiology of stress-induced ischemia and the response to increased levels of stress Discuss some clinical applications of stress echo for non-ischemic conditions Contemplate workflow considerations of exercise and pharmacological stress echocardiography applications avaliable on the ACUSON Redwood™ Ultrasound System Congratulations. You have just finished the online course Stress Echocardiography Review for the ACUSON Redwood™ Ultrasound System. Thank you for your interest! Listed below are the key points. Take time now to review the material here and in the glossary that follows before proceeding to the final quiz.  Course Review Understand the basic physiology of stress-induced ischemia and the response to increased levels of stress. Discuss some clinical applications of stress echo for non-ischemic conditions. Contemplate workflow considerations of exercise and pharmacological stress echocardiography applications available on the ACUSON Redwood Ultrasound System. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages.   All names and data of patients, parameters, and configuration-dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Copyright © Siemens Healthcare GmbH, 2020 Please note that the learning material is for training purposes only! For proper use of the software or hardware, always use the Operator Manual or Instructions for Use (hereafter collectively called “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute for the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of software and hardware available at the time of the training. The Operator Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Note: Some functions shown in this material are optional and might not be part of your system. The information in this material contains general technical descriptions of specifications and options as well as standard and optional features that do not always have to be present in individual cases. Certain products, product-related claims or functionalities described in the material (hereafter collectively called “Functionality”) may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information.   Select the links to review the glossary and the references used in this course. Glossary References When the heart is functioning normally, there is adequate oxygen supply to the myocardium at all levels of activity. Normal coronary function is regulated by the amount of oxygen needed by the heart at rest and with activity. With normal function, the heart rate (HR), cardiac output (CO), and blood pressure (BP) will increase to meet the necessary workload. Normal coronaries dilate and constrict, regulating the blood flow that matches the oxygen delivered to the myocardial muscle. With coronary artery disease (CAD), there is a mismatch of supply and demand. Coronary artery stenosis (CAS) creates a reduced supply of oxygen to the myocardial tissue causing ischemic heart disease. When there is ischemic heart disease, and workload increases, there are detriments to heart rate, blood pressure, and the inotropic state. The ischemic region with CAS will have a regional wall motion abnormality, commonly called RWMA, and the systolic dimensions of the left ventricle (LV) will not thicken properly therefore reducing left ventricular ejection fraction, commonly called LVEF.   Learn more about regional wall motion abnormalities below. Regional Wall Motion Abnormality Learn more about RWMA that can be seen in stress echo testing. Slide NumberText BlocksCalloutsAudio ScriptImage File1Wall Motion and Regional Wall Motion Abnormality. Wall Motion is visually or subjectively assessed at each segment and categorized as either normal, hypokinetic, akinetic, dyskinetic, or aneurysmal.Wall Motion and Regional Wall Motion Abnormality. Wall Motion is visually or subjectively assessed at each segment and categorized as either normal, hypokinetic, akinetic, dyskinetic, or aneurysmal.2Normal function.If systolic thickening improves at all the segments and the end-systolic dimension reduces equally with exercise, this is normal wall motion. If the heart is hypertrophic, systolic thickening can be hyperdynamic, and the systolic dimension can become obliterated.Example of normal systolic thickening at all segments.If systolic thickening improves at all the segments and the end-systolic dimension reduces equally with exercise, this is normal wall motion. If the heart is hypertrophic, systolic thickening can be hyperdynamic, and the systolic dimension can become obliterated.3Hypokinesis.Hypokinesis is a reduction of systolic thickening compared to surrounding tissue. Coronary artery stenosis reduces the oxygen to the myocardial tissue causing some stunning and hypokinetic systolic thickening. Visually subjective hypokinetic stunning can be mild to moderate.View the text that corresponds to the number on the image.CalloutsApex is hypokinetic.Apex is hypokinetic.Hypokinesis is a reduction of systolic thickening compared to surrounding tissue. Coronary artery stenosis reduces the oxygen to the myocardial tissue causing some stunning and hypokinetic systolic thickening. Visually subjective hypokinetic stunning can be mild to moderate.4Akinesia.Akinesia is an absence of systolic thickening altogether. Acute segments of infarcted tissue will be akinetic.  If there is scaring from an old myocardial infarction (MI) that scar will be akinetic. It is common for scared myocardial tissue to be dragged along by surrounding non-infarcted tissue during contraction; this is not systolic thickening.View the text that corresponds to the number on the image.CalloutsApex is akineticCalloutsThe scar is dragged by surrounding muscle contraction.Akinesia is an absence of systolic thickening altogether. Acute segments of infarcted tissue will be akinetic. If there is scaring from an old myocardial infarction (MI) that scar will be akinetic. It is common for scared myocardial to be dragged along by surrounding non-infarcted tissue during contraction; this is not systolic thickening.5Dyskinesia and Aneurysmal wall motion.When there is systolic bulging, the segment or segments are dyskinetic. Systolic bulging is a movement away from the center of the heart. Dyskinesia is different from an aneurysmal segment. Aneurysmal is a geometric distortion seen in systole and diastole.View the text that corresponds to the number on the image.CalloutsExample of a geometric distortion near the apex.When there is systolic bulging, the segment or segments are dyskinetic. Systolic bulging is a movement away from the center of the heart. Dyskinesia is different from an aneurysmal segment. Aneurysmal is a geometric distortion seen in systole and diastole. Treadmill Stress Echocardiography (Treadmill-SE) is a two-stage functional test. Treadmill stress echocardiography is used to non-invasively image the heart of patients that can exercise.  The treadmill speed and incline increase following a standard protocol and patients are exercised to a maximum predicted heart rate (Max-HR) or other clinical diagnostic endpoint is reached. Learn more below. Treadmill Stress Echo Overview Learn more about Treadmill-SE. Tab TitleTextTreadmill-SE Protocol OverviewA resting, standing and supine 12-lead ECG and blood pressure are collected. With the patient turned left lateral and a series of digital echocardiographic images are acquired and labeled as resting. The resting 2D-imaging consist of parasternal and apical views captured as complete R-R cine-loops, triggered by the internal ECG on the ultrasound system or from the external 12-lead ECG. The treadmill stress should achieve 85% of maximum predicted heart rate (85% Max-HR), to the point where the patient experience symptoms, or another diagnostic endpoint. Immediately after treadmill exercise has stopped the same 2D-images are obtained in less than 90 seconds. Workflow Considerations for T-SE2D-images collected at both stages should equal imaging parameters: same depth, same imaging plane, similar gain settings. For Treadmill-SE testing the 12-lead ECG placement needs to be adjusted for 2D-imaging. The pericardial V2 should be moved away from the pericardial access, and V5 should be moved down for apical access. Continuous Capture Once enabled, Continuous Capture allows for a rapid uninterrupted streaming of the 2D-imaging sequence until all of the views are obtained.  Digital cine-loop ‘clips’ that are collected during continuous capture can be reviewed after the patient is recovering. These immediate post treadmill views are selected and saved to the post treadmill stage and used for comparison to the same views that were collected during the resting stage.Treadmill-SE Ischemic Heart Disease The objective of T-SE is to uncover an inducible RWMA, that demonstrates some reduction in systolic wall thickening. The immediate post-treadmill images should be collected rapidly as a continuous digital loop. If there is mild ischemia, mild RWMA or transient ischemia – wall motion stunning may recover very quickly once the treadmill stops and the stunning phenomenon may reverse, and be completely missed by 2D-imaging. Treadmill-SE Non-Ischemic Heart DiseaseFor non-ischemic heart disease treadmill exercise can is used to assess the functional state and hemodynamic responses to exercise capacity. In non-ischemic heart disease treadmill echocardiography can help unmask of a host of parameters under exercise conditions including improvement or worsening LVEF, changes in valve area, pulmonary artery pressure (PAP), or to provoke dynamic valvular symptomology. Additionally, pulse oximetry can be added to monitor oxygen saturation.                                           Treadmill Stress Echo Redwood™ Treadmill-SE on the ACUSON Redwood Ultrasound System. Slide NumberText BlocksCalloutsAudio ScriptImage File1The Treadmill-SE workflow on the ACUSON Redwood Ultrasound System is flexible and adaptable. Treadmill-SE workflows include digital cine-loop collection with or without digital video streaming using a continuous frame capture called 'continuous capture'. Additionally, Treadmill-SE protocol on the ACUSON Redwood Ultrasound System allows with or without View Control.View the text that corresponds to the number on the image.CalloutsDigital Cine-Loop on All StagesContinuous Capture on Peak StageThe Treadmill-SE workflow on the ACUSON Redwood Ultrasound System is flexible and adaptable. Treadmill-SE workflows include digital cine-loop collection with or without digital video streaming using a continuous frame capture called 'continuous capture'. Additionally, Treadmill-SE protocol on the ACUSON Redwood Ultrasound System allow with or without View Control. 2When view control is enabled the 2D-imaging parameters from resting translate to the post stage so both stages will have equal imaging parameters: same depth, same imaging plane, similar gain settings. For Treadmill-SE with View Control enabled, a corelating reference view from the resting stage will display for the post stage.  Additionally, view control assists in view labeling the post views.    View the text that corresponds to the number on the image.CalloutsReference Image of the Parasternal Long Axis view from the Resting Stage.When view control is enabled the 2D-imaging parameters from resting translate to the post stage so both stages will have equal imaging parameters: same depth, same imaging plane, similar gain settings. For Treadmill-SE with View Control enabled, a corelating reference view from the resting stage will display for the post stage. Additionally, view control assists in view labeling the post views. 3If other views are needed, the protocol can be adapted. There is a list of standard images to choose from or a user-defined view can be added to one or all stages.View the text that corresponds to the number on the image.CalloutsAdd a ViewIf other views are needed, the protocol can be adapted. There is a list of standard images to choose from or a user-defined view can be added to one or all stages.4Additionally, if clinically indicated on the Treadmill-SE protocol, recovery stages can be added “on-the-fly” as indicated or customized as part of a particular workflow.View the text that corresponds to the number on the image.CalloutsAdd a StageAdditionally, recovery stage is clinically indicated on the Treadmill-SE protocol, that stage can be added “on-the-fly” as indicated or customized as part of a particular workflow.5Doppler can also be added to one or all Treadmill-SE stages. As clinically indicated, Doppler data can be collected outside of the stress protocol on any stage.  If Doppler is indicated during continuous capture, continuous capture can be paused and restartedView the text that corresponds to the number on the image.CalloutsDoppler - Tricuspid Regurgitation from the Touch ScreenPausing the Protocol if Doppler or other information is required 'Outside' of the Stress protocol.Doppler can also be added to one or all Treadmill-SE stages. As clinically indicated, Doppler data can be collected outside of the stress protocol on any stage. If Doppler is indicated during continuous capture, continuous capture can be paused and restarted 6To review a comprehensive step-by-step guide of Treadmill-SE configuration, instrumentation, and Treadmill-SE workflows avaliable, you can review courses here in PEPConnect.   To review a comprehensive step-by-step guide of Treadmill-SE configuration, instrumentation, and Treadmill-SE workflows avaliable, you can review courses here in PEPConnect. Bicycle Stress Echo (Bicycle-SE) is a multi-stage functional test. The workload measured in watts (W) is the force against the wheel of the ergometer that creates resistance against the pedal. Learn more below.   Bicycle Stress Echo Overview Learn more about Bicycle-SE. Tab TitleTextBicycle-SE Protocol Overview Resting 2D-imaging is collected. 12-lead ECG and blood pressure are collected at rest, and for every stage. The low stage can begin from 25 to 50 W lasting for approximately three minutes. At that time, low stage 2D-imaging is collected, and the next interval begins. Typically, the workload increases in increments of 25 W until the patient achieves an HR of 100 – 120 BPM, then 2D-imaging is collected, and the workload (in watts or W) is noted. The intervals then increase to the peak, which is when the patient becomes symptomatic, or any hemodynamic or significant ECG change occurs. A recovery stage can also be monitored with 2D-image and Doppler documentation. Workflow Considerations for Bicycle-SEThe ideal bike is a semi-recumbent ergometer with easy access to apical views. An upright bike is more difficult to acquire echocardiography during exercise but can be excellent for capturing peak hemodynamic Doppler changes.  Coaching the patient to lean forward over the handlebars is necessary for Doppler and apical views. For Bicycle-SE testing, 12-lead ECG placement needs to be adjusted for 2D-imaging. The pericardial V2 should be moved away from the pericardial access, and V5 should be moved down from apical access. Bicycle SE has several advantages over treadmill SE. The first advantage is that a bicycle has multiple stages of assessing heart function with 2D-imaging at any workload applied. LV dysfunction changes can be rapid, with Bicycle-SE the clinician and patient are already in place for 2D-imaging. Alternately, if the exertion is impacting 2D-imaging or Doppler, bike pedaling can stop momentarily for rapid access of heart function. Bicycle-SE ischemic heart disease For ischemic heart disease ventricular stunning, hypokinesis, from mild ischemia could potentially recover after the treadmill stops. Bicycle-SE wall motion is monitored throughout the exercise and at more than one stage. So, even if there is a mild RWMA or transient ischemia, wall motion stunning can be seen under echocardiography.Bicycle-SE non-ischemic heart disease A variety of non-ischemic valvular heart disease can be assessed using Doppler during graded exercise like Bicycle-SE. Flexible, the Bicycle-SE can be tailored for the individual patient, tracking 2D-images and Doppler with each stage from the low, medium, to peak, and as needed recovery stage. In some non-ischemic cardiomyopathy cases, a depressed ventricular function may improve with graded exercise. Hypertrophic cardiomyopathy (HCM) a type of non-ischemic heart disease that can be tested with Bicycle-SE. HCM can have a pathological dynamic left ventricular outflow (LVOT) obstruction that occurs with exercise and can recover quickly once exercise stops. Monitoring pulse oximetry while exercising the oxygen saturation and hemodynamic responses to an LVOT obstruction are captured with 2D-imaging and Doppler during the stressor. In patients with high pulmonary artery pressure (PAP) have a resting PAP ≥ 25 mmHg. Measuring tricuspid regurgitation (TR) Doppler gradients and monitoring oxygen saturation, the response is measured with graded exercise on the bike. Stress-induced changes in mitral valve (MV) regurgitation and MV area can be assessed with Bicycle-SE.[1-3] Bicycle Stress Echo on the Redwood™ Learn more about Bicycle-SE on the ACUSON Redwood Slide NumberText BlocksCalloutsAudio ScriptImage File1The Bicycle-SE workflow on the ACUSON Redwood Ultrasound System is flexible and adaptable. Bicycle-SE workflows include digital cine-loop collection and the length, type and number of beats is configurable. Additionally, peak stage views can be collected using continuous frame capture or continuous capture.  View the text that corresponds to the number on the image.CalloutsDigital cine-loops for each view and stage.Continuous sigital loop for peak stage.The Bicycle-SE workflow on the ACUSON Redwood Ultrasound System is flexible and adaptable. Bicycle-SE workflows include digital cine-loop collection and the length, type and number of beats is configurable. Additionally, peak stage views can be collected using continuous frame capture or continuous capture. 2It is important to maintain all of the 2D-imaging parameters from resting stages to each of the exercise stages within the Bicycle-SE protocol. Every stage must translate the same imaging depth, same imaging plane, similar gain settings translated across each view within each stage. When view control is enabled, a reference view will be applied for every view and the 2D-imaging parameters from resting will translate to the remaining exercise stages.View the text that corresponds to the number on the image.CalloutsLocation of the Reference View avaliable with View Control.CalloutsLocation of the Reference View avaliable with View Control.It is important to maintain all of the 2D-imaging parameters from resting stages to each of the exercise stages within the Bicycle-SE protocol. Every stage must translate the same imaging depth same imaging plane, and similar gain settings translated across each view within each stage. When view control is enabled, a reference view will be applied for every view and the 2D-imaging parameters from resting will translate to the remaining exercise stages.3If other views are needed, the protocol can be adapted. There is a list of standard images to choose from or a user-defined view can be added to one or all stages.View the text that corresponds to the number on the image.CalloutsSoft Key location to Add ViewIf other views are needed, views can be added to one or all stages during the exam. There is a list of standard images to choose from or a user-defined view can be added to one or all stages.4If another stage is required on the Bicycle-SE protocol, such as a recovery stage, then that stage can be added as clinically indicated or customized as part of a particular workflow.View the text that corresponds to the number on the image.CalloutsSoft Key location to Add StageRenamed the view RECOVERYIf another stage is required on the Bicycle-SE protocol, such as a recovery stage, then that stage can be added as clinically indicated or customized as part of a particular workflow.5Doppler can also be added to one or all Bicycle-SE stages. As clinically indicated, Doppler data can be collected outside of the stress protocol on any stage. Again if Doppler is indicated during continuous capture, continuous capture can be paused and restarted.Doppler can also be added to one or all Bicycle-SE stages. As clinically indicated, Doppler data can be collected outside of the stress protocol on any stage. Again, if Doppler is indicated during continuous capture, continuous capture can be paused and restarted. There are a variety of clinical pharmacologic stress echocardiography applications used in ischemic and non-ischemic heart disease. In this section dobutamine stress echo (DSE) will be reviewed. DSE is a multi-stage functional test. Intravenously infusing increasing doses of dobutamine at three-minute intervals.  Learn more below. Dobutamine Stress Echo Overview Learn more about DSE. Tab TitleTextDSE Protocol Overview Beginning with a low dose stage of 5 µg/kg/min and increasing to 10, 20, 30, and 40 µg/kg/min. The stages in a DSE protocol where 2D-images and Doppler are collected can include a variety of infusion rates. Commonly the DSE stages are resting, low dose stage, moderate, a peak response, and as needed a recovery stage. Addint additional 2D-images and spectral or color Doppler is an option. Commonly for the peak stage, if 40 µg/kg/min of dobutamine doesn’t provoke the endpoint HR response, Atropine can be added to achieve peak HR response. [2,4,5]Workflow Considerations for DSEFor DSE testing, 12-lead ECG placement needs to be adapted for 2D-imaging. The pericardial V2 should be moved away from the pericardial access, and V5 should be moved down from apical access. BP is monitored at every stage and as needed. If the image quality is non-diagnostic, contrast-enhanced agents (CEA) use is appropriate.  If clinically indicated and depending on the laboratories DSE protocol, a chronotropic drug, typicaly Atropine can be given at 0.25 mg intervals with a maximum of 1 mg to help achieve the maximum heart rate. Handgrip exercises, in addition to maximum dobutamine, can also help increase HR. DSE ischemic heart disease In ischemic heart disease, low dose DSE can help assess myocardial viability. After an infarction, or after thrombolysis to relieve acute coronary artery stenosis, if the myocardium is stunned but still viable, that tissue is likely to recover from revascularization therapy. If the tissue is necrotic, the damage is irreversible. If there is an improvement in wall motion demonstrated during low doses of dobutamine that decreases again at the peak stage, this is a biphasic response. The biphasic response may indicate viable myocardial tissue.DSE non-ischemic heart disease DSE can help evaluate the hemodynamic responses of patients with aortic stenosis (AS) that are being evaluated for aortic valve (AV) surgery or transcatheter aortic valve (TAVR) surgery. In patients with severe aortic AS, dobutamine testing can assess changes in stroke volume (SV), contractile reserve, and the transvalvular gradient for aortic valve area (AVA). Post valvular replacement, DSE is useful when patients symptoms are not matching with resting 2D-imaging valvular performance. Dobutamine Stress Echo on the Redwood™ Learn more about Dobutamine-SE on the Redwood™ Slide NumberText BlocksCalloutsAudio ScriptImage File1The Dobutamine-SE workflow on the ACUSON Redwood Ultrasound System is also very flexible and adaptable. Dobutamine-SE workflows include a collection of the views by digital cine-loop where the number of loops, beat length per view is configurable. Additionally, peak stage views can be collected using  continuous capture.The Dobutamine-SE workflow on the ACUSON Redwood Ultrasound System is also very flexible and adaptable. Dobutamine-SE workflows include a collection of the views by digital cine-loop where the number of loops, beat length per view is configurable. Additionally, peak stage views can be collected using continuous frame capture or continuous capture. 2It is important to maintain all of the 2D-imaging parameters from resting stages to each of the exercise stages within the Dobutamine-SE examination. It is very important that every view across each stage maintain the same imaging depth, same imaging plane, and similar gain settings translated across each view within each stage. When view control is enabled, the 2D-imaging parameters from resting translate to the remaining exercise stages.View the text that corresponds to the number on the image.CalloutsPLAX view RestPLAX view PeakPSAX view RestPSAX view PeakReference View interface when View Control is enabled.It is important to maintain all of the 2D-imaging parameters from resting stages to each of the exercise stages within the Dobutamine-SE. It is very important that every view across each stage maintain the same imaging depth, same imaging plane, and similar gain settings translated across each view within each stage. When view control is enabled, the 2D-imaging parameters from resting translate to the remaining exercise stages 3If other views are needed, the protocol can be adapted. There is a list of standard images to choose from or a user-defined view can be added to one or all stages. View the text that corresponds to the number on the image.CalloutsAdding a View from the Soft KeysIf other views are needed, views can be added to one or all stages during the exam. There is a list of standard images to choose from or a user-defined view can be added to one or all stages.4Additional stages may be added to the Dobutamine-SE protocol as clinically indicated or “on-the-fly.”  Stages can also be customized as part of a particular workflow for a specific Dobutamine-SE protocol.  As clinically indicated, stages can be skipped or advanced.  Labeling for additional drugs, such as Atropine, can be added after the images are acquired.View the text that corresponds to the number on the image.CalloutsAdding Post Stage "on-the-fly"Adding a Recovery Stage "on-the-fly"Location on the Soft Keys for adding a StageAdditional stages may be added to the Dobutamine-SE protocol as clinically indicated or “on-the-fly.” Stages can also be customized as part of a particular workflow for a specific Dobutamine-SE protocol. As clinically indicated, stages can be skipped or advanced. Labeling for additional drugs, such as atropine, can be added after the images are acquired. 5Doppler can also be added to one or all Dobutamine-SE stages.   As clinically indicated, Doppler data can be collected outside of the stress protocol on any stage.  If Doppler is indicated during continuous capture, continuous capture can be paused and restarted.View the text that corresponds to the number on the image.CalloutsExample of Doppler within a protocol in continuous capture.Doppler can also be added to one or all Dobutamine-SE stages. As clinically indicated, Doppler data can be collected outside of the stress protocol on any stage. If Doppler is indicated during continuous capture, continuous capture can be paused and restarted In general, stress echocardiography (SE) is a non-invasive functional test that captures myocardial and hemodynamic function while the heart is under an increased workload and oxygen demand. The heart function is captured using two-dimensional (2D) cine-loops, these are called ‘views’. Views are collected at rest and at every exercise stage to examine the myocardial and hemodynamic function while the heart is under an increased workload and oxygen demand.   The level of stress increases to a diagnostic endpoint. At the conclusion of the exam, the observed views are assessed across each stage for comparison. Treadmill and bicycle are stress echocardiographic methods that require the patient to exercises to a level or levels of increasing workload. Non-exercise functional testing includes pharmacologic SE testing. In Pharmacologic-SE testing, a drug, typically Dobutamine is gradually infused at every stage for a graded heart rate response. Both exercise and pharmacologic echocardiography use 12-lead electrocardiography (12-lead ECG) monitoring. In non-ischemic heart disease, increasing cardiac workload unmasks cardiac involvement by augmenting cardiac hemodynamics in both adult and pediatric populations. Doppler can capture dynamic changes during increased workflow revealing changes to the valve orifice area or valvular insufficiency that would not normally be seen at rest.[11,12,13]  In patients with a very low LVEF, 2D-imaging under increasing workload can assess baseline function when planning for major surgery.[2,3]