CONFERENCE EDITION files/Events and...Alex McLaughlin STP Representative, Southampton General...

ISSUE 103 SEPTEMBER 2018

CONTENTS include:

Presidents Message4

Notice of AGM 20186

AGM Minutes 20177-10

Committee Reports 201711-14

BSEcho 2018 Provisional Programme16-17

Guidelines: Pulmonary Hypertension Assessment 19-32

C O N F E R E N C EE D I T I O N

ISSUE 103 SEPTEMBER 2018

ECHO

ECHO is published four times per year. It is the official publication of the British Society of Echocardiography the contact address is: BSE Administration, Docklands Business Centre, 10-16 Tiller Road, Docklands, London E14 8PX, Tel. 020 7345 5185, Fax 020 7345 5186, Email [email protected]. Members of the society are invited to submit articles, case reports or letter correspondence.Submissions should be to ‘The Editor’, ECHO and forwarded by email to: [email protected]. The format should be text as a normal word document and images supplied as high resolution jpeg, tiff, eps or pdf files. Other formats including powerpoint or of web image construction may result in reduced resolution and may be unacceptable.Articles should contain appropriate references. References to be constructed with the first two authors, thereafter abbreviate to ‘et al’, then article title, followed by journal reference.Submissions to ECHO are currently not peer reviewed but may soon become so, changes will be advised. The Editor has discretion on acceptance. Patient consent is required for case reports.If the submitted article (or a very similar version) has been submitted for or been published by another journal, the submitting author(s) should clarify this at the time of submission to ECHO with a justifiable reason for requesting re-publication. Additionally, permission from the previous publisher should be obtained and submitted.It should be noted that opinions expressed in articles or letters are the opinions of the author(s) and not of the council of the British Society of Echocardiography (BSE). Official BSE council views or statements will be identified as such.Information in respect of advertisements can be obtained from [email protected]. Editor

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INSTRUCTIONS TO AUTHORS

PAGE 3

2018 BSE COUNCIL MEMBERS

CONTENTSPage 4 President’s Message

Page 6 Notice of AGM 2018

Page 7-10 AGM Minutes 2017

Page 11-14 Committee Reports 2017

Page 15 BSEcho 2018 Industry Sessions

Page 16-17 BSE Annual Meeting & Exhibition Programme

Page 19-32 Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography

OFFICERSPresident: Keith Pearce Wythenshawe Hospital ManchesterImmediate Past President: Dr Rick Steeds University Hospital BirminghamVice President: Dr Vishal Sharma Chair of Education,

The Royal Liverpool & Broadgreen University Hospitals TrustHonorary Secretary: Jane Lynch Wythenshawe Hospital ManchesterHonorary Treasurer: Jude Skipper Queen’s Hospital Essex

ELECTED MEMBERS Sue Alderton Royal Liverpool HospitalsChris Attwood York, Teaching HospitalsStephanie Baker Grantham and District HospitalDr Claire Colebourn Chair of Accreditation,

John Radcliffe Hospital, OxfordDr Chris Gingles BJCA representative, Ninewells Hospital, Dundee Dr Anita MacNab Wythenshawe Hospital ManchesterShaun Robinson Papworth Hospital Martin Stout Wythenshawe Hospital Manchester

CO-OPTED MEMBERS (1 year term)Dr Brian Cambpell SCST Representative, Guy’s and

St Thomas’ NHS Foundation TrustDave Hatton Lead Regional Representative,

East Kent Hospitals Dr Tom Ingram Chair of Clinical Standards,

Royal Shrewsbury HospitalAlex McLaughlin STP Representative, Southampton

General HospitalProfessor Mark Monaghan BHF Liaison, Kings College

Hospital, London Dr Sitali Mushemi-Blake Deputy Treasurer, Guy’s and St Thomas’

NHS Foundation TrustProfessor Petros Nihoyannopoulos Hammersmith Hospital

Editor, Echo Research & PracticeDr Niall O’Keeffe ACTACC representativeDr Andrew Potter Whaddon Medical Centre, BletchleyKathryn Watson Industry Representative, GE HealthcareDr Gordon Williams Editor, ECHO. York Teaching Hospitals

PRESIDENT’SMESSAGE

Well they say time flies; the past 12 months have been an exciting time for the Society and myself in the role as president of the British Society of Echocardiography. With the opportunity to recap on the key objectives I outlined in Edinburgh 2017, it is with a real pleasure we can start to see some of these areas being realised. The objectives of the society can only be realised with the fantastic input from its council, committee and sub-committee members and, of course, the BSE office staff. These people are the real workers of this fantastic society and without their dedication and commitment the society would simply not exist. At last year’s AGM I outlined some key areas of work and would like to offer a brief update on progress thus far.• Development and Implementation of Level 1 accreditationDr Claire Colebourn was tasked or maybe ambushed by myself and Dr Vish Sharma with the challenge of developing and delivering an accreditation process aimed at Level 1 accreditation. This is a significant challenge which attempts to realise and recognise that whilst echocardiography is undertaken in many areas outside the echo lab, the standards and QA approach to echocardiography should be the same as the echo departments themselves. The sub-committee undertaking this challenge have performed incredibly; the development of a curriculum, the realisation of a process including a logbook/portfolio of evidence and a practical assessment process (1st pilot undertaken in Bristol on Sunday 16 September) is a real testament to the entire accreditation committee and the passion for the accreditation process demonstrated by every one of them. We are certain there will be some bumps along the way although I am confident there will be a significant demand for this process and hopefully we can encourage departments to become engaged with their acute medical/A&E colleagues in delivering this quality assured process. This work is in addition to the work undertaken by others and Claire in delivery of the electronic logbook for accreditation which according to my own trainees is a major positive step forwards.• Increase public patient involvement Under the stewardship of the BSE GP representative Dr Andrew Potter the society has been involved in discussions with the British Heart Foundation in identifying a group of patient representatives who will become involved within specific areas of the society. The patient group so aptly named “Wavelength” are hoping shortly to receive applications from potential patient representatives and after appropriate selection Andy is looking to place these individuals within sub-committee areas such as Research/Departmental Accreditation etc. If you have a specific interest or experience in the patient/public engagement arena I am sure Andy will be open to discussing and potentially involving you in this venture.• Website Redesign The Society has been operational for some 20+years now and throughout my involvement over the past 10 years with the BSE I often hear people comment “the website content is fantastic, it’s just impossible to find exactly what you’re looking for”. With this in mind we entered into a process of redesign/modernisation of the BSE website. One of the first key areas was not only to identify a suitable provider who could deliver this product (Frank design) but more importantly implement a new sub-committee to the society portfolio (communications committee) This committee is made up of only a small group at present to ensure key decisions are made and operates under the guidance of Kelly Victor cardiac scientist at St Thomas’s hospital she has entered into the world of IT and websites like a duck to water. Kelly’s drive and ability to ensure engagement of the key stakeholders across all the subcommittees within the society has enabled our designers, the BSE office staff and Kelly to hold weekly meetings to discuss key areas for development, sign these off and move onwards with the website process. The members have not yet seen any of this work which is going on in the backroom of the society, however with the anticipated release date of April 2019 we will hopefully be able to deliver a service to all members which will not only raise the electronic profile of the society but make your lives a little bit easier in navigating your way through the BSE electronic platform. Keep your eyes open for the new BSEcho brand coming your way soon. • Presidential challenges/charitable fundraising I have no idea who suggested this crazy initiative, however, after many discussions

I was convinced to represent the BSE on a charity bike ride from London to Paris over 3 days. This event was organised by Wil Woan and the patient charity Heart Valve Voice who provided a platform for patients who have undergone valvular heart surgery and professional colleagues form trusts across the UK to mix was a fantastic experience. Riding with clinical perfusionists, anaesthetists, cardiac surgeons and specialist nurses outside of the everyday working environment gave me time to understand the pressures/challenges they face as part of their working lives and their involvement along the entire patient journey. It was a real pleasure to spend some quality time with colleagues outside the working environment. As somebody who doesn’t tend to go out and ask people directly for sponsorship monies, I still managed to raise a small amount in the region of £750 which has been donated to our own Echo in Africa initiative. More importantly the opportunity to raise the awareness of not only valvular heart disease but also the necessity for echocardiography to be utilised in the detection, surveillance and management of patients was definitely worth the sore legs. I have also managed to convince Wil that the BSE would be looking to send some other victims next year on this event or maybe our society can take its own team to ride alongside the HVV contingency. Please keep an eye out for the rallying call.Despite these key objectives being a focus of this year’s summary, I need to bring your attention to the enormous amount of work being undertaken by all the people involved within thr committees, sub committees and office of the society, it is impossible to name everybody but I would like to personally thank a few individuals without causing offence to anybody who I may have missed in this brief overview. Dr Tom Ingram and Stephanie Baker have been instrumental in setting up a further new committee for clinical standards, they have been quietly working away in the background in areas such as DA and further development of the Echo Quality Framework which I am sure you will see more of at this year’s annual BSE meeting. Thanks are given to Dr Rick Steeds for his ongoing support and advice to myself in addition to his tenacious, determined somewhat bulldog like approach to the issues around workforce and shortage of cardiac physiology/scientists. Rick has managed to play a pivotal role in the redesign of a new survey around echo workforce this time with the direct involvement of NHS England, which will be coming to screens near you in the not so distant future I would encourage everybody to participate and help Rick to further drive of the importance of the workforce and education in the delivery of a high quality 7 day echo service.Thanks are also given to one of the busiest people I have ever met; Dr Vishal Sharma not only acts as Vice President to the BSE in addition to Chair of Education, he has significant involvement as co editor in chief for Echo Research and Practice and many other areas of cardiology sitting outside the BSE. Despite this he is always available for a phone call to discuss things and often presents the opposite argument to the discussion which is exactly what you would want from the Vice President. This ensures the society takes a complete view of all the topics and decisions the council makes. Thanks to Jude Skipper for her commitment, for the society for taking on the role as treasurer in a real time of need and thanks to Sitali Mushemi who has acted as deputy to Jude for the past 12 months and has now taken over the reins as treasurer for the society. I am sure we won’t be spending any more money without a robust business case proving cost benefit.This last paragraph of thanks goes to the BSE office staff. This year has seen a significant turnover in office staff with Gill Daniel and Leanne Cohen choosing to leave the society for new ventures; we are thankful for their input to the society and wish them every success for their future careers. To the office staff who are still with the society, Manjinder Virdi and Jo Thanjal, it is recognised they have done a fantastic job, not only undertaking the tremendous amount of work they do but also providing a seamless transition into a new office structure. In order to promote a new approach for the society, the council took the decision to appoint a short term strategy consultant with the aim to identify a future office structure for the BSE to ensure ongoing sustainability and remove over-dependence on individuals. To this point Caroline Barker OBE is undertaking this work for the society and will be presenting her findings and future recommendations to the Council in November. You will find Caroline and the office staff around the conference and any recommendations or suggestions you have would be welcomed as I am sure they want to understand the members experience of the society. You will also come across 2 new office staff Nasreen Begum, Operations and Communications Officer and Hatty Grant, Marketing and Events officer. Whilst new to the society they have both already demonstrated their value and drive and we hope they enjoy working for the BSE.To those I have not named personally I really appreciate the hard work and effort from everybody.

Keith Pearce, President

TRAVEL + ACCOMMODATIONCATCH THE TRAIN ACC Liverpool is a short taxi or bus ride away from Liverpool Lime Streetstation and its direct services to London that take little over two hours. Regional and local railconnections are even closer... TAKE THE BUS Many bus routes serve the bus station at the Liverpool ONE retaildevelopment, just a five-minute walk from ACC Liverpool. For door-to-door service, we offerdrop-off areas and dedicated coach parking. COME BY CAR Less than 20 minutes from the UK motorway network and adjacent toLiverpool’s main through road, ACC Liverpool is perfectly placed if arriving by car. PARKING The Liverpool Waterfront Car Park, ACC Liverpool's onsite car park, is currentlyclosed, there are lots of nearby alternatives for parking. More information here. WALK OR CYCLE Wide waterfront boulevards and pedestrian plazas make walking or cyclingto ACC Liverpool pleasant and safe. FLY TO LIVERPOOL Liverpool John Lennon Airport features charter and low-cost scheduledflights to a range of domestic, European and international destinations. All from theconvenience and ease-of-access of a regional UK airport and an international airport atManchester just 45 minutes away. ACCOMMODATION Negotiated rates in Liverpool have been arranged by ReservationHighway. Accommodation can be booked on line at www.reservation-highway.co.uk/echo18. These accommodation options are local to the venue in Liverpool, where we have a limitednumber of rooms. Delegates may wish to search for alternative options.

REGISTER NOW BSECHO.ORG/BSECHO2018

NEED HELP? CONTACT HATTY AT [email protected]

BSEcho2018The British Society of Echocardiography's 27th annual clinical + scientific meeting

FRIDAY 5 + SATURDAY 6 OCTOBER 201810 BSE RE-ACCREDITATION POINTS

SAY HELLO

HAVE A QUESTION?Visit us at stand 6 to meet our council members and the office team. We will be happy to answer any questions you might have as well astake any suggestions on board.

2018 NOTICE OF AGMANNUAL GENERAL MEETINGThursday 4th October 2018 18:00 – 19:00 hrs

Notice is hereby given that this year’s Annual General Meeting of the British Society of Echocardiography (the “Company”) will be held at the ACC Liverpool, on Thursday 4th October 2018 to transact the business set out below.

1 ACCOUNTSTo receive and approve the draft accounts of the Company for the financial year ended 31 March 2018 together with the report of the directors.

2 OTHER BUSINESSTo transact any other business appropriate to be considered at an Annual General Meeting, including:

(a) apologies for absence;(b) to receive and approve the minutes of the 2017 Annual General Meeting;(c) notification of deaths;(d) Company activities;(e) Honorary Secretary’s Report, including the election of new Council members and membership summary;(f) Honorary Treasurer’s Report;(g) appointment of the Company’s bankers, lawyers and independent financial examiner; • Accreditation report • Communication report • Departmental Accreditation report • Education report • President’s address;(h) Presidential handover(i) any other business, including matters arising from the 2017 Annual General Meeting minutes and not

dealt with elsewhere or any matters raised by members and not covered elsewhere in the Agenda. To ensure an accurate reply, any questions to be raised here must be notified to the President at least 48 hours prior to the Annual General Meeting.

By order of the BoardKeith Pearce, President

British Society of EchocardiographyDocklands Business Centre, 10-16 Tiller Road, London E14 8PXNote to the Notice of Annual General Meeting of the CompanyA member may appoint a proxy to attend the Annual General Meeting on their behalf. Please contact Jude Skipper, Honorary Secretary for further details.

CHANGE HEALTHCARE CASE STUDY - SLIGO UNIVERSITY HOSPITAL2017 AGM MINUTESUnconfirmed minutes of the Annual General Meeting of the British Society of Echocardiography LimitedHeld on Thursday 9th November 2017 at 18:00 Edinburgh International Conference Centre, EdinburghPresent: 12 members attended the meeting

1. Welcome:Dr Rick Steeds welcomed those attending the meeting. He presented slides of the names of Council Officers, Committee Chairs, Council members and representatives from other professional bodies, organisations and groups and extended his thanks to all. He informed the meeting that Dan Knight had stepped down from Council due to other commitments and that this and other vacancies would be appointed to at the Council Meeting on 28th November 2017. He extended BSE’s thanks to Gill Daniell, Jo Thanjal, Manj Virdi and Leanne Cohen and to all the exhibitors and volunteers for all their hard work in making the Annual Meeting successful.

2. Apologies: Stephanie Baker, Jane Allen, Sarah Ritzmann, Shaun Robinson, Claire Colebourn, Sue Alderton

3. Minutes of the 2017 AGM These were agreed as a correct record.Proposed Vishal Sharma, seconded Thomas Mathew. Passed unanimously.

4. Matters arisingThere were no matters arising

5. Notification of deathsNone reported

6. Secretary’s report – Jude SkipperNumber of current members are 3491.The results of the elections to Council were announced. Stephanie Baker (Grantham and District Hospital), Anita MacNab (University Hospital of South Manchester), Shaun Robinson (Papworth Hospital) and Martin Stout (University Hospital of South Manchester) were elected to Council.Thanks were extended to all those that stood for Council but were not successful on this occasion.

7. Treasurer’s report – Vishal SharmaThe finance report was published in the conference edition of ECHO and in the conference delegate programmeVish thanked Manj Virdi (BSE Finance Officer), the Company’s bankers and Accountant and Independent Financial Examiner for their hard work.Motion to re-appoint Company’s bankers (NatWest Bank and Bank of Scotland)Proposed Rizwan Sarwar, seconded Martin Stout. Passed unanimously.Motion to re-appoint Company’s Accountant and Independent Financial Examiner (Philip Kobbs Ltd)Proposed Martin Stout, seconded Christopher Gingles. Passed unanimously.

Motion to re-appoint Company’s Lawyers (Wilsons)Proposed Christopher Gingles, seconded Jane Lynch. Passed unanimously.Motion to re-appoint Company’s Financial Partner for Investment Portfolio (Chase de Vere)Proposed Rick Steeds, seconded Jude Skipper. Passed unanimously.The presented finance report was year ending 31st March 2017.A summary of the accounts was presented.Income – there was an increase in the annual membership fee last year and therefore an increase in annual subscriptions with an income of £239,990. Accreditation income remained fairly static with an income of £108,749. There was an increase in revenue from meetings at £299,095 with the London meeting being very successful with almost 1000 attendees. Thanks were conveyed to Thomas Mathew for organising the meeting. BSE invested £300,000 in March last year and £35,564 of interest had been generated from the investment. Total income for the year was £728, 656.Expenditure – the cost of the Annual Meeting last year was £195,538. Accreditation costs had increased again at £164,835. This compares to £136,863 the previous year and approximately £90,000 in 2014. Costs have therefore almost doubled over a 3 year period. The other increase was seen in management/administration, due to an increase in staffing, to £221,524. In 2014 this was approximately £167,000. BSE increased its bursary scheme spending £7,169 compared to an approximate spend per year of £1,800. Total expenditure for the year was £741,351.The surplus for the year was approximately £14,000 however this does not include the income and expenditure for the Echo in Africa project which is kept separate as it is a restricted donation. If this is included the overall surplus was £18,377.Further details were given with regard to Accreditation costs. Income remains static however costs have increased and there was an approximate £56,000 loss last year. BSE have moved to an on-line process for logbooks (logbook portal) with significant costs of around £18,000 related to this. Two members of staff had been working on accreditation but with the move to Pearson Vue and an office restructure this will be reduced back to one.Questions from the floor in regard to the Treasurer’s report:NoneRequest to approve the accounts for the financial year ending March 31st 2017Proposed Thomas Mathew, seconded Martin Stout. Passed unanimously.

8. Committee reportsThe following reports were published in the conference edition of ECHO and in the conference delegate programme:Departmental Accreditation Committee – Jane AllenAccreditation Committee - Jane LynchEducation Committee – Thomas Mathew, Anjana SivaRick asked if there were any questions with regard to the published reports. AccreditationIt was asked whether BSE would start to generate income from Accreditation once the new processes were embedded. Jane Lynch explained that although the exam fees would be increased it was unlikely that BSE would make a profit but would hope to break even. It was explained that Accreditation is a core member service and BSE does not wish to profit from it. BSE wants its Accreditation process to be the core professional exam in the UK.It was pointed out that there had been an increase in applications from Registrars and a concern raised with regard to the number of practical sessions available. In response to this BSE had organised an additional

practical session at Barts with 40 available places. All candidates on the waiting list had been contacted and only 14 places taken up to date. Ways of advertising this practical were discussed and a number of people volunteered to assist with making people aware of the additional session.With the move to Pearson Vue there are no waiting lists for the theory exam and all applicants have been accommodated. Departmental AccreditationThere will be a new Clinical Standards Committee, Chaired by Tom Ingram, which will incorporate Departmental Accreditation. Jane Allen has stepped back from Departmental Accreditation and Stephanie Baker and Sarah Ritzmann will lead on this in the new committee structure.EducationThomas Mathew apologised for the omission of the attendance figures in the published report. 997 people attended the Annual Meeting in London. The Committee had met on 3 occasions last year and not 4 times as published. He also pointed out that the Advanced Imaging day would be held on 27th April 2018 at the RSM and not 28th April 2018 as stated in the report. There had been a delay in developing the Question Bank and it was likely that it would be 6 months before this was completed.CommunicationsAdele stepped down as Chair of Communications last year and a replacement was still to be found. People had expressed an interest in the position and this was one of the vacancies that should be filled at the Council meeting on 28th November 2017.The Picker survey would be replicated this year beginning at this conference. At the last Department of Health Echo subgroup meeting it was suggested that 54% of Trusts had said that they would be able to deliver 24/7 Echo services. The Picker survey has therefore been altered with a question relating directly to 7 day services and the ability to provide Echocardiography within the specified timeframes 24/7.Since the Departmental Accreditation website broke down there have been ongoing discussions at BSE Council with regard to rebuilding/purchasing a new website.

9. Outgoing President’s report and Presidential handover – Rick SteedsRick thanked everyone for a great experience over the last 3 years and for the time and commitment shown by all. He conveyed his thanks to the Council Officers and to Gill and the office team.Rick provided a summary of where we were 3 years ago and where we are now.Accreditation processes have improved and it is now a speedy, efficient and respected process. There is no longer a backlog of logbooks and feedback has shown that candidates, whether they pass or fail the practical exam, think it is a very useful process.Rick set himself Quality Standards at the start of his Presidency. Stress Echo Accreditation and Stress Echo protocols have been achieved. Unfortunately the National Database for Outcomes hasn’t come to fruition however Rick intends to continue to work on this.Rick also wanted to deliver a Quality Assurance Framework and although this has not actually been delivered there is an outline developed by Nav Masani and Tom Ingram and he feels that this will be something that can be delivered timed with the upgrading of the BSE website.Rick had hoped to encourage a broader and more inclusive membership and feels that we are moving in that direction.Rick gave an update of his work on the Department of Health 7 day services sub-group and thanked Vish for bringing in a health economist to assist with the options analysis. He was pleased that it was acknowledged that the Secretary of State for Health and Social Care has now heard of Echocardiography. There are now proposals for Level 1 Echocardiography that should be delivered in the context of quality. There will be further meetings to discuss networks for delivery and review.Rick acknowledged the need to increase the numbers of Echocardiographers who can deliver level 2 accredited Echocardiography and informed the meeting that there have been discussions about providing

regional network trainers.With regard to other projects, ERP is now indexed with PubMed and hopefully next year will get an impact factor. The Echo in Africa project has had its first paper published in ERP and there are plans to expand the project.Rick praised again the support and commitment from Gill and the office team. Following on from Dawn Appleby was an extremely hard act to follow but Rick thanked Gill for taking over the role extremely well.Rick was pleased that BCS are now far more aware of Physiology issues than they were 3 years ago and that the two organisations are now working well together.Rick re-iterated his thanks to all those on Council and to the Chairs of Committees and handed over the Presidency of BSE to Keith Pearce.

10. Incoming President’s Message – Keith PearceKeith thanked Rick on behalf of The Society for the phenomenal drive and leadership he has shown during his Presidency. Rick becomes the Immediate Past President and it has been agreed that he will remain as BSE’s representative on the Imaging Council. Rick has also agreed to remain on the Department of Health Echo subgroup for 7 day services. Keith conveyed his admiration that Rick had always represented Echo rather than representing a discipline and had pushed the Physiologists agenda tremendously. Keith will endeavour to have the same ethos.Keith outlined the key areas he wishes to concentrate on during his Presidency.Development and implementation of Level 1 Accreditation – Claire Colebourn is leading on this and Keith feels that the engagement of clinical staff is key in the success of delivering this project.Development and implementation of the Clinical Standards Committee – this will include Departmental Accreditation.Public and patient involvement – Keith feels this is a key element for The Society going forward. The public and patient voice is extremely powerful and the engagement of other charities such as Pumping Marvellous has already been of benefit. Keith is keen to have a lay member on Council.Website redesign – this will need significant financial investment but is a key requirement.Council – Keith is eager that Council becomes a body to ratify decisions. The sub-committees perform extensive work and they should present their proposals to elected Council members and the BSE executive for approval.Improve/develop relations with EACVI and ASE – BSE is considered as part of the international Echo community in regards to clinical guidelines and recommendations. Keith hopes to strengthen this and obtain endorsement from other societies when BSE’s policies and procedure guides are published.Development of BSE Fellowship – Keith aims to align BSE with other societies by developing a Fellowship and encourage BSE members and international members to apply for Fellowship with BSE. Criteria will be drafted and circulated in 2018.Identify ambassadors and patrons of The Society – to help raise the profile of BSE it needs to become more recognised in other clinical areas. The Society has a limited social media profile and as such it is inadvertently holding itself back. The concept of Echo is clear to all our members however the general public needs to become more aware of what the technique does and the importance it plays in diagnosing multiple forms of heart disease/illness.Presidential Challenges – fundraising opportunities such as running in the London Marathon, golf days etc to raise funds to support bursaries and fund people to go to Echo in Africa amongst others projects.

11. Any other businessNone

Keith Pearce closed the AGM at 19:02.

COMMITTEE REPORTS 2017/18DEPARTMENTAL ACCREDITATION AND CLINICAL STANDARDS COMMITTEE Departmental Accreditation2017 has been a busy year for the Department Accreditation team with six sites obtaining accreditation (including one in the Republic of Ireland and one in Northern Ireland) and four being reaccredited. Well done to all centres.Accredited:

• Community Cardiology Care Plus Group, Grimsby• Leeds General Infirmary• North Tees and Hartlepool• South Eastern Health and Social Care Trust, Northern Ireland• Sligo University Hospital• Whaddon Medical Centre

Reaccredited:• Blackpool Victoria NHS Trust• Eastbourne District General Hospital• Guys and St Thomas Hospital, London• Kings College Hospital, London

It is encouraging to see several new departments working to-wards Department Accreditation this year and up to April 2018 we have seen the following departments achieving accreditation.Accredited:

• Barts Health NHS Trust, London• Morecambe Bay Hospitals NHS Trust

Reaccredited:• Queen Elizabeth Hospital, Birmingham• Morriston Hospital, Swansea• Brighton and Sussex University Hospitals NHS Trust• York Teaching Hospital NHS Trust

We would like the thank the office administrators and the dedi-cated team of inspectors for all their support over the past year.This is an exciting time, particularly with the new BSE website being created, and we would again encourage departments to apply for accreditation as it is not just for those that are large or highly-specialised centres. The process is supportive and non-judgemental with the ultimate goal of helping as many depart-ments as possible achieve accreditation status.Finally, November 2017 saw Jane Allen step down as Depart-ment Accreditation lead after working tirelessly for many years ensuring the smooth running of the committee; service to which the accreditation team and the wider BSE are extremely grateful.

Clinical StandardsThe Department Accreditation team has been working closely with the newly formed Clinical Standards Committee to cre-ate an echo quality framework to assist departments with their quality assurance process. The model is a new, outward-looking, approach to quality assurance that is centred around improving patient care through utilising feedback processes and reflective practice. The revamped BSE website will be used as a single point of reference/contact to enable departments to succinctly demonstrate adherence to the framework process. Although involvement with the echo quality framework is separate to de-partment accreditation we envisage significant synergy between the two, with both processes linking together to promote high-quality patient care.Echocardiography is increasingly being performed by differ-ent practitioners in different environments. Furthermore, the

provision of echocardiography as an early diagnostic tool for the acutely unwell patient is patchy and under-resourced. In recogni-tion of this shift in practice and to support this exciting growth of echocardiography the committee has been working closely with the BSE Level 1 team and the Intensive Care community to cre-ate a set of standards for satellite echo services within the acute hospital environment.

Sarah Ritzmann and Stephanie Baker,Leads for Departmental Accreditation

Tom IngramChair, Clinical Standards Committee

ACCREDITATION COMMITTEEThis year accreditation processes have started to see the benefits of major changes made to our examination processes over the past three years.The committee now has 35 working members with individualised responsibilities working under the five sub-committee chairs for each of our examined disciples:Level II transthoracic echoNew Level I transthoracic accreditationCritical care transthoracic accreditationTransoesophageal echoStress echocardiographyYou will notice that we now have an entirely new discipline in Level I transthoracic echocardiography, part of the proposed solution to seven-day echo services proposed by the BSE to the DoH. This new process is designed to look for and identify pathology needing immediate treatment presenting to any of the routes of entry to secondary care. This development is being lead by Dr Dave Garry and Dr Rakhee Hindocha and the first examination will take place in November of this year. There is no written component to this exam but the practical examina-tion encompasses live scanning skills, identification of pathol-ogy, log-book review and process quality in delivering an urgent echocardiography service. For full details please see the new accreditation pack on the BSE website or talk to a member of the accreditation team.Written examinations are now delivered in collaboration with Pearson-Vue examination centres offering professional examina-tion environments to all our candidates in a location, which suits them and includes centres in Ireland and South Africa. Pearson-Vue deliver exam for many professional UK bodies and we welcome their high standards of invigilation (please see Pearson-Vue website for full details) and their ability to provide each candidate with an individual computer terminal. This gives each candidate the best chance of clearing seeing the images used for the second section of the written paper and the ability to scroll back and forth through different images.We are working with Pearson-Vue to maximise the effective-ness of our written exams at identifying candidates who meet the required knowledge standards regardless of the standard of the cohort they are sitting their exam with. This should improve our testing quality and re-assure candidates that we set knowledge passmarks maximising their chances of success.This year we have delivered nearly 500 written exams in the four disciplines listed below with steady year on year entry numbers

to the written examination:Level II transthoracic echo: 400 per annumCritical care transthoracic accreditation: 10 per annumTransoesophageal echo: 70 per annumStress echocardiography: 20 per annumPractical assessment days are held five times a year for our core disciplines and on three to four separate occasions for stress and TOE examinations depending on the demand for places and examiner availability.This year we have visited Leeds, Birmingham, Oxford, Man-chester and London. We continue to strive for good regional geographical coverage and have a new centre coming on board this year at the Bristol Royal Infirmary. We would like to extend a huge thankyou to our examination centres and please do get in touch if you would like to join our pool. This year we have examined 300 candidates at our practical examinations and accredited 230 with an average pass rate of approximately 70% at each sitting.Practical examination is now the only route to accreditation for new submissions and this has reduced the number of log-books awaiting marking to virtually zero. We have also found that face to face feedback and being a given a result on the day reduces wasted time for candidates needing to re-take part or all of the practical process, and that they leave the exam equipped to re-at-tempt and pass at their next sitting in the vast majority of cases. We are still working hard to standardise our practical processes as much as possible through senior/junior examiner pairing and strong station leadership. We continue to receive, digest and act on comments and observations made by candidates and these are welcomed as an important part of our quality improvement processes.The practical exams are staffed by our formidable pool of asses-sors who give up their weekends time and time again to uphold the high standards of accreditation set by the British Society of Echocardiography; internationally recognised as a unique quality mark in the delivery of safe echocardiography. The BSE council has taken further steps to recognise the importance of our 70 strong group of examiners through the progressive allocation of free admission to the annual BSE conference and advanced imaging meetings and free annual membership for those examin-ers attending four practicals per year. If you would like to join the assessor group then please get in touch with me through Jo Thanjal who manages accreditation in our central office.The new on-line log-book portal is now fully up and running for all our disciplines. All new successful written examination candidates will be issued with a unique log-in to begin collat-ing their log-book for the practical exam. This represents the end product of a lot hard work and listening to feedback from candidates, and will benefit both candidates and examiners by reducing errors in case-counting and anonymisation and provid-ing a central site for supervisor checking and quality assurance ahead of the examination.Accreditation packs are now reviewed or updated annually and are on our website for you to use as a reference. These now includes the new Level I pack which went live this month.Re-accreditation processes have been reviewed and unified to represent a core basic minimum for all disciplines and to encour-age re-accreditation for those who are now very senior in their roles or perhaps have a taken a different career path, and don’t perform as many first operator scans. Re-accreditation can now be undertaken through accumulation of a log-book and a sliding points scale, or through live scanning, evidence of senior-report-

ing and acquisition of points. See the website for full details.What does the future hold?The focus of the committee this year is to further quality assure our practical examination processes and to streamline the stations we use to assess candidates. Over the next two years we hope to have our first practical examination in South Africa so sun-glasses at the ready!I would like the thank all members of the accreditation commit-tee, the BSE assessor group, our practical centres and Jo and Gill at the BSE office for all their hard work this year. I would also particularly like to thank my predecessor Jane Lynch for all her hard work, dedication and care in the role over the preceding three years. Jane has now joined the BSE executive in her new role of honorary secretary.

COMMUNICATION AND WEBSITE COMMITTEE The last year has seen a momentous increase in the British So-ciety of Echocardiography social media presence. We now have 4328 followers on Facebook and our Twitter account supporters has more than doubled compared to 2016 with almost 3000 fol-lowers. Our BSE president (@BSE_President) has also increased his devotee numbers with 174 Twitter enthusiasts. These sites continue to provide an up to date overview of current events hap-pening both at BSE and within the cardiology community. They also help to raise awareness of echocardiography and the work we are doing more widely. We are grateful for your support and hope that we can continue to increase our social media presence in 2019. Another focus over the last year has been the development of a brand new BSE website. A lot of work has been going on behind the scenes in relation to delivering a website with the best functionality for our users. The new platform is aimed at delivery more efficient and high-speed performance. We hope to achieve an interface which is user friendly with enhanced navigation and bespoke functionality for our users so that our members get the best possible experience. Most of you will be aware of GDPR, a new regulation surrounding privacy and the protection of data. We are working hard at BSE to ensure that our website and prac-tices satisfy these regulations. This means we are making every possible effort to ensure your privacy is protected and respected. In the coming months, we anticipate going live with our new website and would very much appreciate any feedback regarding experience from the user’s perspective. Aside from this, the BSE team have been concentrating on ex-panding our communication networks by engaging with various medical and scientific groups, working in collaboration with the American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI). We have also been also to strengthening our network links with PCR, Heart Valve Voice, 6xOPEN and Pumping Marvellous, and we hope that we can maintain these connections going forward. More recently we have been focussing on the patient population and how the patient voice can assist us in improving our current processes. This has resulted in the development of a BSE patient advisor group, ‘Wavelength’, who will help promote excellence in echocardiography, contribute to better patient care and maxim-ise public awareness in relation to the importance of echocardi-ography.We are excited about the work ahead of us and hope that the next year will see further improvements in BSE communication.

Kelly Victor,Chair for the Communications Committee

ECHO JOURNAL COMMITTEE This is a newly formed committee with the direction of having a more structured approach to producing the Echo Magazine. The committee will aim to help the Editor by helping source content for Echo. The committee is in its infancy with roles and respon-sibilities still being defined, but we are hoping to press ahead and make significant positive strides forward over the next year.The current members of the newly formed committee are as fol-lows:• Chris Attwood, Chair• Dr Gordon Williams (Editor) • Gaynor Jones • Debbie Wilson • Dr Sitara Khan • Dr Manahari Balasingam • Cheryl Oxley • Dr Andy Potter • Claire Robb • Linda Arnold

FINANCE REPORT The Society is extremely grateful for the continued support from our finance administrator, Manj Virdi and accountants Moses and Eric, at Philips Kobbs and Co. This has been a significant yet exciting year for the BSE as we bid farewell to key adminis-trative staff, Gill Daniell and Leanne Cohen and rapidly transi-tion into a new administrative structure. From a financial perspective, the operating adjusted results of the Society for fiscal year 2017-18 showed a surplus of £4,693 (2016-17: £18,377) growing total reserves of the Society to £796,332. During the year there were two important digital projects in discussion that we hope will maximise and benefit all BSE membership going forward. The first digital project is BSE’s investment in mission-related activities with Pearson Vue which the Accreditation Committee introduced in November 2017. Exploring digital technologies with the use of Pearson Vue platforms worldwide allows for written exams to be available through their network of exam centres. The second digital pro-ject is being overseen by the Communication Committee. Here, the BSE is investing in a new website, to support strategic areas such as accreditation, education programs, online learning and advertising, whist maximising our online presence. We caution, however, that it will likely take time to see the benefit of these two important changes. Many of the BSE’s sources of income come from membership subscription, annual conference, accreditation, sponsorship, advertising, investment portfolio and donations through generos-ity of donors, which continue to help grow the Society’s income. During 2017- 18 there was a total income of £711,200, which represents a small reduction of £21,529 (-3%), when compared to 2016-17 fiscal year. This lower figure is partly due to the reduced number of delegates attending the Society’s annual conference in Edinburgh. We are pleased to see a continued increase in the number of new and returning members to the BSE, which was reflected in the 10% increase in annual subscription income. Accreditation went up by 10%, although small in size, this increase represents an important income source for the future. The increase in Ac-creditation income was partly due to the following - Pearson Vue portal introduction, and more members taking practical exams,

IncomeSubscriptionAccreditationMeetingsPublication & AdvertisingOtherInvestmentDonations (EIA)Interest received

Total Income

ExpenditureMeetingsAccreditationMember servicesManagement/adminResearch and TrainingTrustee Meeting

Total Expenditure

Surplus

Income brought forward

Total

239,990108,479299,09530,62815,00035,3994,073

65

732,729

195,538164,835108,243221,524

7,16917,042

714,352

18,377

733,262

791,639

264,077119,224219,06728,41537,0509,991

33,34532

711,200

200,260185,161104,197189,010

7,29620,584

706,508

4,693

791,639

796,332

24,08710,745

-80,028-2,21322,050

-25,40829,271

-34

-21,529

4,72220,326-4,046

-32,514127

3,542

-7,844

-13,684

10%10%

-27%-7%

147%-72%719%-52%

-3%

2%12%-4%

-15%2%

21%

-1%

-74%

2016-17 2017-18 Variance %

accrediting and reaccrediting. We are grateful for the continued contributions from our industry partners and exhibitors which are positively reflected in this year’s income. The investment portfolio still generates a healthy return albeit lower figures in comparison to the previous year.Additionally, thank you to Edwards Lifesciences for their dona-tion of £33,345 towards the BSE’s Echo in Africa humanitarian project. We cannot go without mentioning our President, Keith Pearce’s efforts in raising echocardiography awareness through collaboratively taking part in the London to Paris cycle challenge with Heart Valve Voice in the spring of this year.On the whole, the operating expenditure fell slightly year on year. with a total expenditure of £706,508 (2016-17: £714,352). Management and administration costs decreased by 15% or £32,514. The Accreditation administration costs remain high as BSE develops the Pearson Vue portal. It is expected that the new web-site, to be introduced in 2018-19 will result in cost cutting with digital options such as submission of online log books, printing congress badges, accessing online journals etc.This concludes the summary of the key financial highlights for 2017-18 accounts, the finalised detailed information will be presented to Companies House and Charities Commission by January 2019. We encourage all members to attend the annual conference and would welcome any suggestions either via the office at [email protected] or in person at the AGM.

Sitali Mushemi-Blake, Deputy Treasurer

EDUCATION COMMITTE REPORT The Education committee would formally like to thank Dr Tom Matthew who stepped down as chair of the committee following the 2017 conference. Upon taking the post we decided to build upon some of the structures that Tom had put in place and establish more formal sub-committees within the Education committee. These sub committees are:

1. The Programme Committee – Lead Martin Stout, Vishal Sharma

This committee is responsible for organising the Annual Conference, Advanced Imaging and the BSE sessions at the British Cardiac Society meeting. The Annual Conference was held in Edinburgh on the 9th and 10th of November 2017. This was very well attended with 839 delegates attending. A particular highlight was to welcome the Presidents of both the ASE and EACVI to the meeting. Following falling attendance at the social events in recent years, we organised a drinks reception immediately after the conference for delegates rather than a formal meal. The attendance at this event was excellent and the feedback positive so we intend to follow the same format again in Liverpool, 2018. We hope that you will attend this and you will have the opportunity to meet colleagues and BSE council/committee members in an informal setting. We will also be honouring the contributions of previous stalwarts of the BSE at this event. We hope to see in you in at the 2018 conference in Liverpool but please ensure you book early. It is likely to be a very busy weekend on Liverpool with the return of the ‘Giants’, as well as Liverpool playing Manchester City at Anfield on the same weekend. Hotels in particular will be booked up early that weekend and hopefully the atmosphere in the city will be bouncing (unless Man city win!)

The theme of Advanced Imaging this year was Aortic Stenosis and was held on the 27th April 2018. This was incredibly popular and attracted a maximum capacity attendance of 300. In addition there was a waiting list and unfortunately some people trying to register on the day needed to be turned away. In recent years the number of registrations for both advanced imaging and indeed the conference have been close to capacity so again please book early to avoid disappointment.

The BSE/ICE meeting is organized with Dr Anjana Siva as the lead organiser for this meeting. This was held at the Belfast Waterfront on the 11th March 2018 and attracted 133 delegates.

2. Protocols and guidelines- Lead Dan Augustine

Over the last 12 months, the pulmonary hypertension guideline was finalised and published in Echo Research and Practice (ERP). This has also been sponsored by Actelion and the full version will be reprinted in this edition of Echo. Dr Dave Oxborough also led on an update to the sports screening protocol which has also been published in ERP. There has been a significant amount of work on trying to update the BSE’s normal data set, led by Dr Allan Harkness. Changing these data sets is not an entirely straightforward process but hopefully something will be produced in the next 6 months.

3. Online Resources – Lead Chris Gingles

The DLM for Mitral Regurgitation and Aortic Stenosis were released in 2017/8. A new DLM on pulmonary hypertension is almost ready for release. In addition the BSE is planning an overhaul of its website, and we are exploring ways of

improving the online presence of educational material. and was released in December 2017 and remains active.

4. Core Knowledge and BSE exam preparation course– Lead Shaun Robinson/Julie Sandoval

The format of the core knowledge course will be different in 2018 and will include a component for BSE exam and practical assessment preparation. This is due to be held on the 13th and 14th September at Austin Court Birmingham.

5. Research – Lead Sanjeev Bhattacharya

When undertaking work in updating the normal echo data set, it became apparent how few of the ‘normal values’ we use every day and make important clinical decisions on are underpinned by robust data. Consequently the Research subcommittee is looking into the feasibility of conducting a large data collection of echocardiographic data for a normal population.

6. Regional Meetings – Lead Dave Hatton

Dave Hatton has been leading on supporting the delivery of 2 regional echo meetings per year. These will be supported by the BSE in terms of admin support and provision of some speakers. They will also attract a higher number of BSE points that a standard local meeting, reflecting the quality of the content being delivered. If you are keen to have a regional meeting in your area next year please contact us via your regional rep or at the BSE office.

Current membership of the Committee:

• Dr Vishal Sharma, Chair, Lead Programme Committee

• Dr Martin Stout, Vice-Chair, Lead Programme Committee

• Dr Will Bradlow

• Allan Harkness

• Dr Daniel Knight

• Dr Dave Oxborough

• Dr Dan Augustine, Lead Protocols and Guidelines

• Dr Chris Gingles, Lead online resources,

• Nikki Preston

• Dr Liam Ring

• Julie Sandoval, Lead Core Knowledge

• Dr Anjana Siva, Lead BSE/ICE meeting

• Shaun Robinson, Lead Core Knowledge

• Katherine Collins

• Maria Paton

• Kathyrn Watson (Industry Rep)

• Waheed Akhtar

• Dr Benoy Shah

• Maxine Guillen

• Dr Sanjeev Bhattacharya, Lead Research

PAGE 14

SIMULATOR TRAINING BY BSE + HEARTWORKS

B S E C H O 2 0 1 8 I N D U S T R Y S E S S I O N S

Simulator training sessions will run on Friday 5 October and Saturday 6 October at set timesthroughout the day. Please note the following:

Simulator training is restricted to a maximum of one delegate for each time slot In order to make simulator training available to as many delegates as possible; delegates may onlytake part in 1 simulator training session over the duration of the meeting* Delegates may select times for simulator training on both Friday and Saturday, but only one timeslot will be allocated overallNo additional BSE reaccreditation points or CPD points are awarded for taking part in a simulatortraining session

HANDS-ON TRAINING BY SIEMENS HEALTHINEERS, GE HEALTHCARE + PHILIPS

The topics in these sessions include 3D/4D TTE + TOE image acquisition and manipulation, strain andspeckle tracking techniques and other advanced quantification tools. Please see specific companysessions for more details. All sessions are led by company based Applications Specialists and usingtheir respective off-line reporting facilities. Please note the following:

Limited places are available for each session and numbers depend upon the company, maximum of14 per session for Siemens and maximum of 20 per session for GE and Philips Delegates may attend multiple sessions during the conferenceNo additional BSE reaccreditation points or CPD points are awarded for taking part in a trainingsession

You will be required to indicate your preferred training times on the booking form. We strongly recommend that you review theprogramme carefully before making your selection. Training will be allocated on a first come, first served basis however we cannotguarantee availability at one of your preferred times. All delegates must sign in at the BSE registration desk on the morning of the

conference to confirm their attendance to the simulator session. Failure to do so will result in these slots being offered to otherdelegates. *If there are unfilled slots at the start of any training session, at his/her discretions, the Trainer may accept a delegate

who has not booked or who has already taken part in a session previously.

F I N D O U T M O R E + B O O K Y O U R P L A C E A T

B I T . L Y / I N D U S T R Y S E S S I O N S

08:55

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12:30

12:30

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11:00

- 12

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12:30

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- 14

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- 14

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Time to act now and improve patient outcomes with earlier diagnosiswww.ActOnPAH.co.uk

This website has been developed and funded by Actelion Pharmaceuticals UK Ltd to provide information for healthcare professionals.PAH 18/0574. Date of prep: July 2018

1. Pulmonary Hypertension Association UK (2017). What it means to live with PH today. PHA UK. Available from: www.phauk.org. Accessed July 2018; 2. Galiè N, et al. Lancet. 2008;371:2093–100; 3. Sakao S, et al. Am J Respir Cell Mol Biol. 2010;43:629–34; 4. Galiè N, et al. Eur Heart J 2016;37:67–119; 5. Humbert M, et al. Circulation 2010;122:156–163; 6. Humbert M, et al. Eur Respir J 2010; 36:549–555; 7.Condliffe R, et al. Am J Respir Crit Care Med 2009;179:151–157; 8. Dimopoulos K, et al. Circulation 2010;121:20–25

Pulmonary arterial hypertension (PAH) is an incurable condition of the heart and lungs that can have a devastating impact on patients.

PAH shares symptoms with other more common conditions, such as asthma, and is frequently overlooked or misdiagnosed. In the UK, half of patients wait over a year before receiving a diagnosis,1 in this time, irreversible damage could occur.2,3

Echocardiography (echo) technicians play a key role in the evaluation of patients with PAH. Echo should always be performed when PAH is suspected, and may be used to infer a diagnosis.4

Early referral, diagnosis and access to the right treatment is vital for those affected and can improve survival.5–8

The Act on PAH website has been developed by Actelion Pharmaceuticals UK Ltd in collaboration with pulmonary hypertension (PH) specialists and aims to provide the knowledge and tools to earlier identify patients suspected of having PAH.

Learn about the symptoms, diagnosis and treatment of PAH

Access useful tools, expert articles and case studies developed by PH specialists

Find the location and contact details of the specialist centres and advice on how to refer

Keep up to date with ‘Acton PAH’ events, congresses, meetings and study days relevant to PAH

Visit www.ActOnPAH.co.uk to learn more

D X Augustine et al. BSE pulmonary hypertension guideline

G11–G245:3

GUIDELINES AND RECOMMENDATIONS

Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography

Daniel X Augustine MD1,*, Lindsay D Coates-Bradshaw2, James Willis PhD1, Allan Harkness MSc3, Liam Ring4, Julia Grapsa PhD5, Gerry Coghlan MD6, Nikki Kaye7, David Oxborough PhD8, Shaun Robinson MSc9, Julie Sandoval10, Bushra S Rana FRCP11, Anjana Siva12, Petros Nihoyannopoulos MD13, Luke S Howard DPhil14, Kevin Fox FRCP15, Sanjeev Bhattacharyya MD16, Vishal Sharma MD17,†, Richard P Steeds MD18 and Thomas Mathew2,† on behalf of the British Society of Echocardiography Education Committee 1Royal United Hospital Bath NHS Foundation Trust, Bath, UK2Nottingham University Hospitals NHS Trust, Nottingham, UK3Colchester Hospital NHS Trust, Colchester, UK4West Suffolk Hospital NHS Trust, Bury St Edmonds, UK5Hammersmith Hospital, Imperial College London, London, UK6Royal Free London NHS Foundation Trust – Cardiology, London, UK7West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK 8Liverpool John Moores University, Research Institute for Sports and Exercise Physiology, Liverpool, UK9Papworth Hospital NHS Foundation Trust, Cambridge, UK10Leeds Teaching Hospitals NHS Trust, Leeds, UK11Papworth Hospital, Cambridge, UK12Queen Alexandra Hospital, Portsmouth, UK13Imperial College London, NHLI, National Heart & Lung Institute, London, UK14Imperial College London, National Pulmonary Hypertension Service, London, UK15Hammersmith Hospital, London, UK16St Bartholomew’s Hospital, Barts’ Heart Centre, London, UK17Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK18University Hospital Birmingham and University of Birmingham, Birmingham, UK

Correspondence should be addressed to D Augustine: [email protected]

*(D Augustine is the Lead Author)†(Guideline Chairs: T Mathew and V Sharma)

The publication of this article was sponsored by Actelion Pharmaceuticals Ltd. The article was produced by the British Society of Echocardiography independently of Actelion Pharmaceuticals Ltd and they were not able to influence its content. Peer review was carried out independently by the journal’s editorial board, based on scientific merit alone.

Abstract

Pulmonary hypertension is defined as a mean arterial pressure of ≥25 mmHg as confirmed

on right heart catheterisation. Traditionally, the pulmonary arterial systolic pressure has

been estimated on echo by utilising the simplified Bernoulli equation from the peak

tricuspid regurgitant velocity and adding this to an estimate of right atrial pressure. Previous

studies have demonstrated a correlation between this estimate of pulmonary arterial

systolic pressure and that obtained from invasive measurement across a cohort of patients.

However, for an individual patient significant overestimation and underestimation can occur

and the levels of agreement between the two is poor. Recent guidance has suggested that

echocardiographic assessment of pulmonary hypertension should be limited to determining

the probability of pulmonary hypertension being present rather than estimating the

-17-0071ID: 17-0071

Key Words

f pulmonary hypertension

f echocardiography

f guideline

5 3

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

www.echorespract.com © 2018 The British Society of Echocardiography Published by Bioscientifica Ltdhttps://doi.org/10.1530/ERP-17-0071


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pulmonary artery pressure. In those patients in whom the presence of pulmonary

hypertension requires confirmation, this should be done with right heart catheterisation

when indicated. This guideline protocol from the British Society of Echocardiography aims

to outline a practical approach to assessing the probability of pulmonary hypertension

using echocardiography and should be used in conjunction with the previously published

minimum dataset for a standard transthoracic echocardiogram.

Introduction

The British Society of Echocardiography (BSE) Education Committee has previously published a minimum dataset for a standard adult transthoracic echocardiogram (1). This document specifically states that the minimum dataset is usually only sufficient when the echocardiographic study is entirely normal. However, the BSE Education Committee has published a number of supplementary guidelines to cover specific pathologies to be utilised in conjunction with this minimum dataset.

The intended benefits of such supplementary recommendations are to:

• Support cardiologists and echocardiographers to develop local protocols and quality control programmes for an adult transthoracic study.

• Promote quality by defining a set of descriptive terms and measurements, in conjunction with a systematic approach to performing and reporting a study in specific disease states.

• Facilitate the accurate comparison of serial echocardiograms performed in patients at the same or different sites.

In this guideline, the important measurements that should be performed when assessing a patient’s probability of having pulmonary hypertension (PH) are discussed. Some of these views are part of the minimum dataset but the majority are additional. The aim of this document is to provide practical recommendations for the image and analysis dataset required in patients being assessed for possible PH, or where the diagnosis is known and is consistent with the 2015 European Society of Cardiology/European Respiratory Society recommendations on the diagnosis and treatment of PH (2). Estimation of PH in patients with left heart disease such as valvular heart disease remains within current guidelines (3, 4, 5). Estimation of pulmonary artery pressure (PAP) within these patients is reasonable, at rest and during exercise (3, 6) or during follow-up of an individual patient. However, confirmation with

right heart catheterisation (RHC) should be considered, particularly if the presence of PH is a major component of any decision to refer for intervention.

This guideline replaces the previous protocol on PH published by the BSE and will be reviewed and updated in the future as a result of future publications or changes in best practice.

Background

PH is presently defined as an increase in mean pulmonary arterial pressure to ≥25 mmHg at rest as assessed by right heart catheterisation (2). The clinical significance of a mean pulmonary arterial pressure between 21 mmHg and 24 mmHg is unclear. It can complicate many cardiovascular, respiratory and connective tissue diseases. Untreated, morbidity and mortality levels are high (7, 8) and therefore accurate and prompt diagnosis is crucial. The diagnosis of PH requires a clinical suspicion based on symptoms, physical examination and review of a comprehensive set of investigations. Echocardiography is a key imaging modality in the assessment of patients with suspected or known PH.

The classification of PH categorises different clinical conditions into five groups (Table 1). This is an important categorisation for two reasons: first, the most common form of PH encountered in any echocardiography department will be secondary to left heart disease (9) and hence a full study with consideration of indirect measures of elevation in left ventricular end-diastolic pressure must be performed in all cases consistent with the minimum dataset (1); secondly, the interpretation of supportive measurements for classification of patients with intermediate probability of PH, such pulmonary artery acceleration/mid systolic notching, must be taken in the context of the possible underlying cause as these may be more likely in cases with pre-capillary PH.

Each of these groups can further be categorised as to whether there is normal pulmonary arterial wedge




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pressure (an estimate of left atrial pressure) or elevated pulmonary arterial wedge pressure, which may be helpful in identifying the aetiology of PH. The World Health Classification of PH is outlined in Table 1.

The traditional echocardiographic approach to estimating pulmonary artery systolic pressure (PASP) uses a derivation of right ventricular pressure from the tricuspid regurgitation (TR) velocity added to a qualitative assessment of right atrial pressure (RAP). Previous studies have demonstrated good correlation across patient populations but only moderate precision of absolute PASP values calculated from TR velocity (TRV)max (11, 12, 13, 14). This is important as in an individual patient, significant under and over estimation can occur leading to misdiagnosis and inappropriate treatment (15).

There are number of reasons why the level of agreement between the estimated pressures derived by echocardiography and those measured invasively is poor. First, errors may occur in accurate measurement of the peak TRV signal. This can result in both over estimation and underestimation if the quality of the Doppler signals is poor or inaccurate as a result of suboptimal Doppler alignment due to eccentric jets. When estimating right ventricular systolic pressure (RVSP) from the TRV using the Bernoulli equation, the TRV is squared and multiplied by 4, so even small errors in the absolute measurement of TRV can result in significant changes to the estimate of RVSP. Secondly, in order to obtain an estimate of PASP, the RVSP

needs to be added to an estimate of the RAP derived from measurement of the inferior vena cava (IVC) dimensions and response to inspiration. However, in many patients, IVC dimensions cannot be obtained and even in those where measurement is possible, the accuracy between echo estimation of RAP and invasive measurement is as low as 34% (16). Thirdly, it is well recognised that in patients with severe free-flowing TR that the correlation between TRV and RVSP is poor and should not be performed (17). In addition, absence of TR is insufficient to exclude the presence of PH. For example, one study has shown that in patients with scleroderma being screened for PH, if a TRV cut-off of 2.7 m/s was used, this would have excluded some patients who had a mean pulmonary arterial pressure >40 mmHg (18). Furthermore, the expected normal upper limit of PASP depends on BMI (19).

In view of these factors, when screening patients with suspected PH, information obtained from echocardiography can only grade the probability of PH being present rather than provide a definitive diagnosis. Therefore, when assessing the probability of PH, the measurement of TRV should be used in conjunction with other echocardiographic markers of PH. Thus, the information in this protocol is intended to be used as a guide and the data have been selected by consensus using as much evidence base as possible. Future studies assessing the accuracy of this probability-based approach in the diagnosis of PH will be beneficial and add to the evidence base. The invasive measurement of

Table 1 Classification of PH.

WHO group

Aetiology of pulmonary hypertension

Mean pulmonary arterial wedge pressure

Example causes

1

Pulmonary arterial hypertension

Normal

Idiopathic, hereditary, drug or toxin induced, shunts related to congenital heart disease, connective tissue disease, portal hypertension, chronic haemolytic anaemia

2

Pulmonary hypertension secondary to left heart disease

Increased

Valvular heart disease, systolic dysfunction, diastolic dysfunction, pericardial disease, congenital/acquired left heart inflow/outflow tract obstruction, congenital cardiomyopathies

3

Pulmonary hypertension secondary to lung disease

Normal

Chronic obstructive pulmonary disease, severe asthma, interstitial lung disease, sleep apnoea, long term exposure to high altitude, congenital lung abnormalities

4 Chronic thromboembolic pulmonary hypertension (CTEPH)

Normal Chronic pulmonary embolism

5

Pulmonary hypertension with unclear and/or multifactorial mechanisms

Normal or increased

Systemic diseases, sarcoidosis, vasculitis, haematological malignancies, chronic renal failure, metabolic disorders, lung tumours

Adapted from World Health Organisation Classification of PH (10).




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pulmonary artery pressure during right heart cardiac catheterisation is required to confirm or refute a diagnosis of PH.

The first step in assessing the echocardiographic probability of PH being present is to measure the peak TRV. If this is a good-quality signal and is greater than 3.4 m/s, there is a high probability of PH being present. If the peak TRV is below 3.4 m/s, the probability of PH is assessed in combination with other echocardiographic markers.

This approach based on estimation of likelihood is recommended for all clinical groups of PH. Additional considerations in specific subsets of patients are included in the ‘Appendices’ section. The assessment of probability of PH by echocardiography is just one part in the overall clinical judgement as to the presence of PH in a certain individual. Echocardiographic findings should be interpreted alongside other clinical findings to establish the likelihood of PH prior to confirmatory diagnosis as needed by RHC.

Echocardiographic assessment of patents with PH

The flow chart depicted in Fig. 1 is used to assess the probability of PH. The echocardiographic parameters used for grading the probability of PH are set out in Table 2 and described further in Table 3. If the TRV is >3.4 m/s then the echocardiographic probability of PH is high. If the TRV is ≤3.4 m/s, then other echocardiographic parameters suggesting PH must be used to assign the probability of PH. These parameters are split into three categories (A: the ventricles; B: the pulmonary artery; C: the IVC and right atrium). Parameters from at least two different categories are needed to determine the probability of PH.

Echocardiography also provides information about aetiology and prognosis in patients with PH. Patients with established PH or high probability for PH should have full assessment to exclude left-sided heart disease or intracardiac shunts as the cause of PH. Right ventricular dilatation and dysfunction are considered poor prognostic markers in patients with PH. Additional measurements that can be used to assess patients with PH are shown in Table 4.

TR velocity

2.8 m/s ornot measureable

LOW INTERMEDIATE HIGH

> 2.8 & 3.4 m/s > 3.4 m/s

2 echocategories

2 echocategories

No NoYes Yes

Figure 1Flow chart to assess the probability of pulmonary hypertension using parameters identified from within ≥2 categories (the ventricles, pulmonary artery or the inferior vena cava and right atrium) in conjunction with tricuspid regurgitation velocity. Adapted from ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension 2015 (2).

Table 2 Echocardiographic signs used to help grade the probability of PH.

A: The ventriclesa B: Pulmonary arterya C: Inferior vena cava and right atriuma

Right ventricle/left ventricle basal diameter ratio >1.0

Right ventricular outflow Doppler acceleration time <105 ms and/or mid systolic notching

Inferior vena cava diameter >21 mm with decreased inspiratory collapse (<50% with a sniff or <20% with quiet respiration)

Flattening of the interventricular septum (left ventricular eccentricity index >1.1 in systole or both systole and diastole)

Early diastolic pulmonary regurgitation (PR) velocity >2.2 m/s

Right atrial area (end systole) >18 cm2

PA diameter >25 mm

aEchocardiographic parameters from at least two different categories (A/B/C) from the list should be present to alter the level of echocardiographic probability of pulmonary hypertension.




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Table 3 Minimum requirements needed to assess the probability of pulmonary hypertension.

Measurements View (modality) Explanatory note Image

Peak TR velocity A4CPSAX/RV inflow (CW)

Peak TRV is measured by CW Doppler across the tricuspid valve. Multiple views may need to be taken to obtain the optimal window. These include the RV inflow, parasternal short axis (PSAX), apical 4-chamber (A4C) view, subcostal view or a modified view between the PSAX and A4C (20)

Ensure the CW Doppler to flow angle is correctly aligned. Eccentric jets can lead to incomplete Doppler envelopes and underestimation of TR velocity. A high sweep speed (100 mm/s) (21) can help to differentiate between true velocities and artefact

Velocity can be under estimated in severe/free TR and should be stated in the report (see ‘Appendices’ section)

Measure from a complete TR envelope. Choose the highest velocity (average of five beats in atrial fibrillation)

A TRV <2.8 m/s is considered normal (2, 22)

Pulmonary artery (PA) diameter

PSAX (2D) PA dimension is measured in end diastole halfway between the PV and bifurcation of main PA (21)

The PA dilates in response to volume and pressure overload

A diameter of >25 mm is considered abnormal (2)

RV outflow tract (RVOT) acceleration time (AT)

PSAX (PW)

A pulsed wave (PW) Doppler measurement taken after positioning the sample volume just below the pulmonic cusp on the RV side in the RV outflow tract (23)

Measure at end expiration from the onset of flow to peak flow velocity. As pulmonary artery pressure (PAP) increases, the acceleration time of the RV ejection into the PA shortens

Use the average of five beats in atrial fibrillation. Heart rates outside of the normal range (<70 or >100 bpm) may reduce accuracy and a correction for heart rate (HR) may be used (RVOT AT × 75/HR) (24, 25, 26)

When pulmonary pressures measured invasively are >25 mmHg, changes in heart rate have no significant effect on acceleration time (25)

Acceleration time of <105 ms is considered a marker of raised PAP (27)

(Continued)




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Early diastolic PR velocity

PSAX or parasternal RV outflow view (CW)

A CW Doppler measurement through the pulmonary valve in line with the PR jet. Multiple views may be needed to obtain the best PR signal. The peak (early/beginning of diastole) PR velocity (PRVBD) value is measured. This may have additional value when TRV cannot be used or relied upon

An early PR velocity >2.2 m/s is considered a marker of raised mean PAP (2)

Pulmonary systolic notch

PSAX (PW) A PW Doppler measurement taken after positioning the sample volume just below the pulmonic cusp on the RV side in the RV outflow tract (15)

Increased pulmonary vascular resistance and pulmonary arterial stiffness can cause a reflection of waves which return towards the RV during systole. This impedes RV ejection and causes ‘notching’ of the Doppler profile

The presence of a pulmonary systolic notch is considered a marker of raised PAP

The presence of a pulmonary mid systolic notch is more likely to represent increased pulmonary vascular resistance and poor vascular compliance in keeping with pre-capillary PH, rather than PH due to left heart disease (28)

Eccentricity index (EI)

PSAX (2D) Measure from PSAX view at mid LV level between papillary muscle and tips of mitral valve leaflets. End systole is taken as the frame with the smallest LV cavity; end diastole is measured on the peak of the R-wave (29)

The ratio of the minor axis dimensions as shown in the image (D2/D1) measured at end systole and end diastole. D1 = left ventricular diameter perpendicular to the septum; D2 = left ventricular diameter parallel to the septum

RV pressure and volume overload can lead to an abnormal shape and function of the interventricular septum, resulting in flattening

RV volume overload causes eccentricity in diastole only. RV pressure overload also causes eccentricity in systole. Off-axis PSAX images may cause artefactual eccentricity

Left ventricular eccentricity index>1.1 is considered abnormal (2)

RV/LV basal diameter ratio

A4C (2D)

This is measured from the standard A4C view without foreshortening. Measurement is taken at end diastole

Ratio of >1 measured at end diastole suggests RV dilatation (2)

Table 3 Continued.

(Continued)




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Right atrial area A4C (2D) Measure at end ventricular systole on the frame just prior to tricuspid valve opening

Trace the RA from the plane of the TV annulus along the IAS, superior and lateral walls of RA

RAA >18 cm2 is considered abnormal (21, 30)

Inferior vena cava diameter (IVC)

Subcostal (2D M-mode)

Diameter is measured perpendicular to the IVC long axis, 1–2 cm from the RA junction at end expiration

Assess size and percentage reduction in diameter with sniffing or quiet inspiration

IVC diameter >21 mm with decreased inspiratory collapse (<50% with a sniff or <20% with quiet respiration) is considered abnormal (2)

Table 3 Continued.

Additional measurements

Although not required when determining the likelihood of PH being present, a number of other echo markers can be useful in determining the severity of PH and may provide additional prognostic information (Table 4). These are particularly useful in those patients with a

confirmed diagnosis of PH. These markers include right ventricular dimensions (RVD1 RVD2, RVD3), fractional area change and tricuspid annular plane systolic excursion (TAPSE). In addition, the peak systolic RV pulsed tissue Doppler velocity taken at the lateral tricuspid annulus and right ventricular index of myocardial performance (RIMP) can provide further information.




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Table 4 Useful additional features and prognostic findings in patients with established PH.


Pericardial effusion All views (2D) The presence of a pericardial effusion due to PH is a sign of advanced disease with poor prognosis (31, 32)

RV dimensions (RVD1, RVD2, RVD3)

A4C (2D) Due to increasing preload and afterload, progressive right ventricular dilatation is seen with worsening pulmonary hypertension

All measurements are taken at end diastole in the RV-focused view (33). RV size may be underestimated due to the crescentric RV shape

RVD1: Basal RV diameter. Measured at the maximal transverse diameter in the basal one third of the RV. RVD1 >41 mm is abnormal (33)

RVD2: Mid RV diameter measured at the level of the LV papillary muscles

RVD2 >35 mm is abnormal (33)RVD3: RV length (end diastole from the plane of the tricuspid annulus to the RV apex)

RVD3 >83 mm is abnormal (33)

Fractional area change (FAC)

A4C (2D) Manual tracing of the RV endocardial border from the lateral tricuspid annulus along the free wall to the apex and back along the interventricular septum to medial tricuspid valve annulus at end diastole and end systole. A disadvantage of this measure is that it neglects the contribution of the RV outflow tract to overall systolic function

FAC = (RVAd − RVAs)/RVAdRV FAC <35% indicates RV systolic dysfunction (33)

RV pulsed tissue Doppler S wave (Sʹ) velocity

A4C (PW TDI)

PW tissue Doppler S wave measurement taken at the lateral tricuspid annulus in systole. It is important to ensure the basal RV free wall segment and the lateral tricuspid annulus are aligned with the Doppler cursor to avoid velocity underestimation

A disadvantage of this measure is that it assumes that the function of a single segment represents the function of the entire ventricle, which is not likely in conditions that include regionality such as RV infarction (21)

Sʹ wave velocity <9.5 cm/s indicates RV systolic dysfunction (33)

(Continued)




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Myocardial performance index (RIMP)

A4C (PW or PW TDI)

RIMP is an index of global RV performance. The isovolumic contraction time (IVCT), isovolumic relaxation time (IVRT) and ejection time intervals can be measured using tissue Doppler or pulsed wave Doppler

Pulsed wave Doppler or tissue Doppler methods require a sample positioned at the lateral tricuspid valve annulus. However, RIMP derived from pulsed wave Doppler also requires an additional sample from the RVOT and both pulse wave samples need to have near-identical R-R intervals (i.e. heart rate). Tissue Doppler is preferred as it is derived from a single sample

RIMP >0.43 by pulsed wave Doppler or >0.54 by tissue Doppler indicates RV dysfunction (33)

Tissue Doppler values >0.64 are associated with worse prognosis (32)

Tricuspid Annular Plane Systolic Excursion (TAPSE)

A4C (M-mode)

This is an angle dependent measurement and therefore it is important to align the M-mode cursor along the direction of the lateral tricuspid annulus. Select a fast sweep speed

The excursion of the lateral tricuspid annulus is measured by M-mode between end diastole and peak systole

A measure of longitudinal RV systolic function. TAPSE <1.7 cm is highly suggestive of RV systolic dysfunction (33)

Table 4 Continued.




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Other echocardiographic measurements

In addition to the echocardiographic measures discussed in this document, there are other echocardiographic markers that may be of use in assessing patients with PH. These measures include stroke volume, cardiac output and pulmonary vascular resistance, although the value of serial measures of these by echocardiography has not been validated. These measures may be of value where further haemodynamic information is required:

• Pulmonary arterial end-diastolic pressure (PDP). Measure pulmonary regurgitant jet velocity taken at end diastole (PRVED) (Fig. 2).

PDP = 4(PRVED)2 + RAP

• Mean pulmonary artery pressure (31). Measure pulmonary regurgitant jet velocity taken at the beginning of diastole (PRVBD).

Mean PAP = 4(PRVBD)2 + RAP

• Surrogates of heart function (e.g. stroke volume index and cardiac index) have been shown to be associated with prognosis (32, 34). It is possible to estimate these values using echocardiography (Table 5) although the preferred option would be by thermodilution at RHC (2).

• Pulmonary vascular resistance (PVR) can be measured using TRV (m/s) and VTIRVOT (cm):

PVR (Wood units) = 10 × (TRV/VTIRVOT) + 0.16. Here, a TRV/VTIRVOT <0.2 corresponds approximately to a PVR of <2 Wood units (35).

Table 5 Calculations to assess markers of ventricular function.

Measure Echocardiographic assessment

Cross sectional area (CSA) left ventricular outflow tract (LVOT) (LVOT diameter)2 × 0.785

Stroke volume (SV) Velocity time integral (VTI)(LVOT) × Cross sectional area (CSA)(LVOT)

Cardiac output (CO) Stroke volume × heart rate (HR)

Stroke volume index (SVi) Stroke volume/body surface area (BSA)

Cardiac index (CI) CO/BSA

Figure 2Measurement of pulmonary regurgitant jet at end diastole (marked X).




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Appendices

TR assessment

Peak TR velocity is the key parameter in determining the probability of PH, but the TR signal can be absent in a proportion of patients. The prevalence of TR in patients with a PASP ≥35 mmHg is only 80% but increases to greater than 95% in those with PASP >50 mmHg (36). If the TR signal is absent, probability estimation should be based on clinical context taking into consideration other concordant clinical and echocardiographic signs of RV pressure overload (Fig. 1). In patients with a trivial TR jet or sub optimal continuous wave Doppler spectrum, injection of intravenous agitated saline can be considered to improve the Doppler signal allowing measurement of peak TR velocity (37) (Fig. 3). As a default, if clinical suspicion remains, invasive measurement of pulmonary pressures should be recommended.

In patients with severe TR, TR velocity can be significantly underestimated and cannot be used alone to exclude PH. The severity of the volume of TR is distinct from velocity and the probability of PH in this context should be determined in conjunction with other echocardiographic parameters (Fig. 1).

Assessment of PH in patients with left heart disease

This guideline endorses the use of a probability-based approach for the assessment of PH in all clinical subgroups including those secondary to left-sided heart disease. A full assessment including history, ECG and echocardiography will help to identify PH due to left heart disease (38). This is important as left heart disease will be the major aetiology of PH encountered in echocardiography departments (9). If there is an intermediate or high probability of PH then further echocardiographic evaluation should be made to exclude a cardiac cause for PH. In particular, this should prompt a careful assessment of LV systolic and diastolic function, measurement of left atrial volume and exclusion of left-sided valve disease (Table 6). Colour flow Doppler should

be used to exclude atrial and ventricular septal defects. Following a thorough clinical review, a bubble study and transoesophageal echocardiogram may be considered to fully exclude cardiac causes of PH, especially in those patients with confirmed PH.

It is recognised that some guidelines use an absolute PASP value to guide management of patients with PH secondary to left heart disease. In patients with severe

Figure 3TR jet obtained at baseline (top) is improved following injection of intravenous agitated saline (bottom).

Table 6 Features which may suggest left heart disease causing PH.

PH due to left heart disease group Echocardiographic features suggesting left heart disease may be cause of PH

LV systolic dysfunction Dilated LV; reduced LV ejection fraction

LV diastolic dysfunction E/e′ >10 (39); left atrial dilatation (40); left ventricular hypertrophy (38)

Valvular heart disease >Mild valvular disease

Congenital heart disease Presence of intra and extra cardiac defects




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mitral valve disease, a PASP >50 mm Hg is considered a class IIa indication for surgery (3, 4). Evidence for this is largely based on invasive pulmonary artery pressure measurements, but there are limited echocardiographic studies suggesting a prognostic role for PASP derived from TR velocity and RA pressure (41, 42). In this subset of patients, in addition to determining probability of PH using TR velocity, resting PASP can be estimated by echocardiography using standard methods (4). Confirmation by invasive measurement is required before considering valve surgery if elevated PASP is the main or only reason triggering intervention.

Key messages

In patients with suspected PH, the following echo parameters should be used to assess the probability of PH:

1. Peak TR velocity2. Ventricle

a. Eccentricity indexb. Basal LV/RV diameter ratio

3. PAa. RVOT acceleration time and/or mid systolic notchingb. Early diastolic PR velocityc. PA diameter

4. RA and IVCa. RA areab. IVC size and respiratory variability

Conclusion

Echocardiography should be used to assess the probability of PH being present. Confirmation with right heart catheterisation is warranted if a definitive diagnosis of PH is needed, particularly if pre-capillary PH-specific therapies may be indicated.

Abbreviations

A4C Apical four chamberAT Acceleration timeBSA Body surface areaBSE British Society of EchocardiographyCI Cardiac indexCO Cardiac outputCW Continuous waveDT Deceleration timeEI Eccentricity indexFAC Fractional area changeHR Heart rateIVC Inferior vena cavaIVCT Isovolumetric contraction timeIVRT Isovolumetric relaxation timeLA Left atriumLV Left ventriclePA Pulmonary arteryPAP Pulmonary artery pressurePASP Pulmonary artery systolic pressurePDP Pulmonary arterial end diastolic pressurePH Pulmonary hypertensionPHT Pressure half-timePR Pulmonary regurgitationPRVBD Pulmonary regurgitant velocity at the beginning of

diastolePRVED Pulmonary regurgitant velocity at the end of

diastolePS Pulmonary stenosisPSAX Parasternal short axisPV Pulmonary valvePVR Pulmonary vascular resistancePW Pulsed waveRA Right atriumRAA Right atrial areaRAP Right atrial pressureRHC Right heart catheterisationRIMP Right ventricular index of myocardial performanceRV Right ventricleRVAd/s Right ventricular area in diastole/systoleRVD Right ventricular diameterRVOT Right ventricular outflow tractRVSP Right ventricular systolic pressureSV Stroke volumeSVi Stroke volume indexTAPSE Tricuspid annular plane systolic excursion TR Tricuspid regurgitationTRV Tricuspid regurgitation velocityTV Tricuspid valveVmax Maximum velocityVTI Velocity time integral




G235:3

Declaration of interestThe authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this guideline.

FundingThe publication of this article was sponsored by Actelion Pharmaceuticals Ltd. The article was produced by the British Society of Echocardiography independently of Actelion Pharmaceuticals Ltd, and they were not able to influence its content. Peer review was carried out independently by the journal’s editorial board, based on scientific merit alone.

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Received in final form 24 April 2018Accepted 11 May 2018Accepted Preprint published online 11 May 2018



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