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Interview with James D. Thomas

Tue, 20/12/2011

Interview #1: James D. Thomas, President of The American Society of Echocardiography

We just came back from the EUROECHO 2011 conference in Budapest. We heard a lot of very interesting talks and met with some of the greatest echo masters. These are the masterminds of echocardiography if you will.  And here is the best thing of all: they shared some of their wisdom with you - the 123sonography community. We asked all of them three highly relevant questions like:

  1. What’s the best way to become an echo expert for someone who is just at the start of his or her echo career?
  2. What are the most common echo mistakes you see in your daily clinical practice?
  3. What’s the best advice you ever got from a mentor?

We got some incredibly useful answers that we would like to pass on to you. So in case you don't have an echo mentor, let our masterminds mentor you. In case you do have a mentor, let them be your mastermind group! So without further ado…..let’s welcome our first EUROECHO 2011 mastermind:


James D. Thomas
President of the American Society of Echocardiography

Check out the best advice, James ever got from his mentor Dr. Weyman early on in his career. Then read the interview with him, you will learn a lot of valuable echo tips and tricks!

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123sonography: What advice would you give to someone who is just getting started on echocardiography? 

James D. Thomas: While you need to learn the physics and the basics of imaging from books, there is absolutely no substitute for a good teacher. It varies around the world who that teacher might be. In the US a lot of the echo acquisitions are done by sonographers. Early on it’s important for every cardiologist to acquire their own images, even if later in their careers, most of their images are going to be acquired by sonographers; you still need to have the skills to acquire them yourself. At the Cleveland Clinic, the first year fellows work closely with our senior sonographers and learn the proper technique for holding the probe, managing the instrumentation settings and just develop a very automatic, intuitive approach to doing the echocardiogram. We want them to be able to put the probe on the patient’s chest and instantly start to integrate what they are seeing with their eyes with the patient’s story, moving the probe and coming up with a comprehensive exam at the end.
You can read every book in the world but you will never get that final touch unless you work with a real expert who takes the time to teach you and give you the tips about the hands-on stuff.
123sonogrpahy: So are you saying that this should be the first thing a novice in echocardiography should do – find the proper teacher?
James D. Thomas: I am not saying that it has to be the very first thing. I think that there is a point in studying the theory first. I think you need to know the echo basics to understand what you are doing and to know what will happen if you twist this or that knob. That can be done on your own. But very soon, you need to get yourself in a situation where someone can lead you through an exam and lead you through different pathological states, for example to  show you “OK, this is mitral regurgitation, these are the views you need to get and you may need to this and that to highlight the jet”….and things like that.
123sonography: We have a lot of readers who don’t  have a mentor or teacher. What would be the best way to find a mentor or teacher for a person like that?
James D. Thomas: It depends on local conditions. I trained in Dr. Weyman’s laboratory in Boston and we had a number of people who came from around the world there. I recall a gentleman coming from Nigeria and he was going to be the first physician with an ultrasound machine in the whole country of Nigeria and somehow he found a grant from the World Health Organization to come to Boston to spend a few months there. At the end of his stay he was not as well trained as one of our cardiology fellows there but when he went back to Nigeria and got his ultrasound machine at least he knew how to start to use it. And from there you can start to self-teach yourself.

Today of course there is a lot more available on the web. Your site off course has a lot of tips and instructions. I am the president of the American Society of Echocardiography, we have a whole host of educational material available on the web. Another key is that when you move beyond the very basics of echocardiography and move into the diagnostic phase, your focus is more than just making good pictures but also making correct diagnoses.

Then you really need to read the guidelines. We must have around 50 or more guidelines from the American Society of Echocardiography. Many of them we have done with the European Association of Echocardiography and we have a very collaborative relationship with each other where we often co-sponsor guidelines. We just had a publication on using echo to guide transcatheter interventions in cardiology. We are putting together guidelines on the assessment of patients who have had chemotherapy or radiation therapy. Thus, these are topics where a group of experts have come together and thought hard about putting down what they think the right approach is. If a person reads those guidelines, they will be well on their way in gaining the knowledgebase to become a good echocardiographer.

We understand that not all people in the world who are interested in echocardiography are comfortable with English. So we have now translated seven of our guidelines into Mandarin. We have recruited a whole host of Chinese echocardiographers to work with Feng Xie, one of our American cardiologists who is from China. He has organized about 30 of them to translate and crossed-check each other’s work, and now they are being distributed on the web, on CD’s and on posters being distributed across China. Similarly we have translated 3 guidelines into Spanish, and we may be doing this in Portugese as well.  We are also open to other languages if we can find the translators. We have even been approached by an ASE member from the Republic of Georgia offering to translate guidelines into Georgian!
123sonography: What are some of the most common mistakes you see when you watch people perform echo. Mistakes that could be easily avoided.
James D. Thomas: I am just going to give you some examples. Take mitral regurgitation for example. The Cleveland Clinic is a center of excellence for mitral valve repair. So I am constantly being sent patients who are said to have severe mitral regurgitation and need surgery, even though they are asymptomatic. The most common cause of me seeing a patient, evaluating them and then sending them back home without undergoing surgery is a very simple mistake. People err by looking only at the maximal size of the jet. So you see a still-picture, and there is a big jet or a big proximal convergence zone. But they don’t pay attention to the duration of the jet, the time course of the regurgitation.

For instance, in mitral valve prolapse, the jet may only occur in the last third of systole. It’s the classic “late systolic click murmur syndrome,”  and so, yes, they may have a regurgitant orifice of 0.5 cm2, but it only lasts for 100ms and not 300ms. So they have only one third of the volumetric impact on the heart and if the ventricle size is normal, the atrium is only mildly enlarged, pulmonary pressures are normal and they are asymptomatic with good functional capacity, then we are very comfortable watching those people. A good trick to pick this up is if you just put a plain old CW-Doppler through the valve. You will see a very faint envelope of the regurgitation, and then when it really starts you’ll see a very dense envelope. In just one glance, you can say that this is a late systolic MR event.

Conversely, patients who have functional MR – ischemic mitral regurgitation for example –may show a big jet early in systole as the valve is closing; as the ventricle gets smaller later in systole, the valve will coapt better, the jet will stop, and you don’t see a big jet come back until isovolumic relaxation when the valve spreads apart once again. And that patient may look like they had severe MR on a single frame or a single proximal convergence zone analysis but really it’s only moderate.
123sonography: Any other mistakes?
James D. Thomas: I see a couple of mistakes in the assessment of aortic stenosis. Aortic stenosis is something we think is easy, and when everything makes sense, it actually is rather straightforward. If your gradient correlates well with the valve area you calculate and also with the patient’s symptoms and the appearance of the ventricle then it’s fine. You have all the information you need to make a surgical decision.

But there are situations where you might calculate a valve area that’s very small but you measure only a low gradient, most commonly seen when the patient has poor ventricular function. When you have an ejection fraction of 15% or so, you may want to do a dobutamine echo to see whether you raise the gradient while you keep the valve area small [i.e., true stenosis] or conversely whether the valve area increases but the gradient stays the same, demonstrating that the patient mainly has just poor left ventricular function [i.e., pseudostenosis]. But often you have a small valve/low gradient situation, there is some technical problem with how they have  measured the annulus or the left ventricular outflow tract specifically underestimating the size of the left ventricular outflow tract, which gives them a small valve area.

Or you see things flipped around the other way where you have a calculated valve area that seems too big for the very elevated gradients measured. Often this is real and reflective of a high output state from anemia, fever, thyrotoxicosis, or severe AR.  However, you can also have a situation where the place where you measure your sub-aortic velocity is not the place where the annulus is 2cm in diameter. It’s down where a bulging septum has narrowed the LVOT down to maybe 1.2cm causing sub-valvular acceleration so it looks like you have a larger valve area than you really do.

One trick I use in those patients is to approach the continuity equation in other ways. Remember, all you need to calculate the valve area is a stroke volume, which you then you divide by the time-velocity integral of the CW-Doppler through the aortic valve. Conventionally we get the stroke volume using the PW-Doppler in the LVOT together with the annular measurement. But you can also do it by measuring the stroke volume from the left ventricle - very carefully measuring the 2D or ideally 3D volumes, optimally with contrast. You can also do it by looking at a right-sided stroke volume using  flow through the pulmonary artery. If you calculate that RVOT stroke volume and then divide it by the time velocity integral of the CW-Doppler through the aortic valve, that will also give you the aortic valve area and provide you with a check of the valve area that you calculated through the conventional way. If the two agree, then you can have greater confidence in your measurements, but I often found that this clears up the apparent discrepancy between valve area and gradient and suddenly it makes sense.
123sonography: Could you explain the calculation again?
James D. Thomas: You take the aortic stroke volume from the 2D or 3D measurement of the LV or from the RVOT, basically from wherever you can  get it, even a PA catheter, and divide it by the time-velocity integral of the aortic valve. Stroke volume is in cubic cm and time-velocity integral is in cm and cubic cm divided by cm gives cm squared. That should give you the aortic valve opening area and is a good check to make sure that things make sense there.
123sonography: Thank you so much James for your time!
James D. Thomas: It was a pleasure to talk to you

James D. Thomas also has an interesting blog over at the ASE website. Here are some selected posts that you might want to read:


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