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CASE (Phila)
CASE (Phila)
CASE : Cardiovascular Imaging Case Reports
2468-6441
Elsevier

S2468-6441(24)00146-4
10.1016/j.case.2024.06.002
Editorial
What Does It Mean When You Report a Normal Study?
Sorrell Vincent L. MD, FACP (honorary), FACC, FASE, FSCCT, FSCMR CASE Editor-in-Chief
University of Kentucky Gill Heart & Vascular Institute, Lexington, Kentucky
19 8 2024
8 2024
19 8 2024
8 8 401403
2024 Published by Elsevier Inc. on behalf of the American Society of Echocardiography.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmc “We are the normal, we live and we die with no reason why.” (lyrics by John Rzeznik, Robby Takac, George Tutuska and Paul Westerberg from We Are the Normal; Superstar Car Wash (Album); Goo Goo Dolls [1993])

“But the trouble with normal is it always gets worse” (Bruce Cockburn for song / album: The Trouble with Normal; 1983)

I was finalizing a transthoracic echocardiographic (TTE) report this morning, and it was quickly apparent to me that the study was entirely normal. This is not something I see very often at our university-affiliated, hospital-based, adult echocardiography laboratory. In fact, we don't even have a drop-down option in our structured reporting tool to state “normal study.” This got me wondering what the requesting medical provider would have thought had I simply stated “This is a normal study” in my final conclusions.

Pondering a bit more upon the comprehensive report that I had just signed, started me thinking about what it means to report “this is a normal study” and how this conclusion means different things for different tests (and for different interpreters). For this editorial, I applied this same mental exercise to each of the commonly performed cardiac noninvasive diagnostic imaging modalities to better understand the value of a normal result.

By a wide margin, the cardiovascular examination from a routine conventional 2D, Doppler, and m-mode TTE is the most comprehensive analysis available on your heart. For decades now, we have all developed respect for the complementary value of the other advanced imaging modalities, but these are incrementally rewarding relative to the full gamut of findings with a well-performed, quality TTE.

A normal stress myocardial perfusion imaging (MPI) nuclear SPECT (Single Photon Emission Computed Tomography) scan, a normal cardiac computed tomography (CCT) scan, or a normal cardiovascular magnetic resonance (CMR) scan are very powerful test results when each is reported. They provide us with important diagnostic (through the exclusion of pathologic findings) and prognostic information to manage our patients with suspected cardiovascular disease. But none of these other normal studies has the comprehensive value offered with a normal (high quality), comprehensive TTE report.

For example, a normal CCT is a wonderfully prognostic test result. Truth be told, I would prefer to have a normal CCT over a normal invasive coronary angiogram (which may miss mild atherosclerosis and coronary calcification). It also provides some clues to the cardiac chamber dimensions, valve and myocardial pathology, and may occasionally find an unexpected anomalous vessel or patent foramen ovale or a host of non-cardiac findings (pulmonary, musculoskeletal, etc). A major limitation on the value of a normal CCT, which is focused on the coronary arteries, versus a normal TTE is the lack of physiologic information such as ventricular (or atrial) function.

A normal MPI SPECT offers excellent clinical outcomes with very low incidence of ischemic events in the near future. It should also provide a multi-beat averaged estimate of the left ventricular size and function (albeit, with a low temporal resolution relative to TTE). It does not evaluate the cardiac valves or the pericardium and the myocardial assessment is limited to ischemia or infarction. A more favorable comparison would be nuclear stress MPI versus dedicated (limited to 2D) stress echo. This is why it has been my experience that stress echo is usually combined with a Doppler echo or a temporally obtained comprehensive TTE to off-set the limited nature of stress echo alone.

A CMR is likely the second most comprehensive cardiac study and when normal, should offer many of the same findings available from a normal TTE. One might presume that a normal CMR might even be superior to a normal TTE if basing that presumption entirely on what's been published rather than personal experience. Full disclosure, some readers have probably heard me (jokingly) say that a CMR is “like an echo on steroids.” With that comment, I mean that many of the findings on a complete TTE can be obtained with a complete CMR, but with higher quality, higher precision, and additional incremental findings on myocardial characterization using early and late gadolinium contrast kinetics. So why do I remain steadfast that a normal TTE report is more revealing than a normal CMR report? I believe it is three-fold. (1) Echo is a mature, widely available diagnostic tool and most labs have the ability to provide a similar, comprehensive final product. By comparison, CMR is a diagnostic tool that is often targeted toward a pathology in question and, despite being capable of providing a comprehensive conclusion, it more often includes selected sequences and therefore, selected conclusions (Editor note: there are many similarities to how a focused TEE is often performed versus a comprehensive TEE that is possible); (2) Echo is able to exclude small, mobile findings on valves (such as infective vegetations) that are simply below the spatial and temporal resolution of clinical CMR; and (3) Echo Doppler provides an unparalleled assessment of hemodynamics (noninvasive pressure estimates), valve physiology, and low velocity findings (such as myocardial motion for diastolic function assessment) that CMR, even when phase-contrast sequences are included, is unable to match.

So, what did my report from this entirely normal comprehensive echo study actually look like? Instead of simply stating normal, I included each of the relevant pertinent negative findings as a means to optimally communicate what a ‘normal echo study’ actually means. Importantly, my final impression always addresses the clinical question being asked by the requesting provider. The indication for this study was listed as “murmur and palpitations.” (Editor note: as is often the CASE, there were no details regarding the description of the murmur, and I was left with making some assumptions). I included that each of the valves were well-visualized without evidence for stenosis, sclerosis, or prolapse (at rest). I mentioned that the estimated cardiac output was normal, not high. I mentioned the normal LV mass and normal heart chambers while specifically emphasizing the normal left atrial volume index. This included a comment that an agitated saline bubble study was performed and was normal (no cardiac or intra-pulmonary shunt). I concluded that a comprehensive Doppler study did not find significant regurgitation or stenosis and that there were no findings to suggest an aortic coarctation.

Just for fun in an effort to demonstrate the different implications from a normal reported study based upon the diagnostic modality, I prepared a short table of 24 common cardiovascular findings that should be routinely reported (Table 1).Table 1 Value of a normal report

Finding	Normal TTE	Normal CMR	Normal SPECT	Normal CCT	
LV size	++	++	+	++	
LV function – sys	++	++	+	+ (gated protocol)	
LV function – dias	++	-	-	-	
LV mass/wt	++	++	+	+	
LV myocardium	+	++	+	+	
Myocardial ischemia	+ (stress protocol)	+ (stress protocol)	++	-	
RV size	++	++	+	+	
RV function	++	++	+	-	
RV mass/wt	+	++	-	+	
LA size	++	++	-	++	
LA function	++	++	-	-	
RA size	++	++	-	++	
MV/TV stenosis	++	+	-	+	
MV/TV prolapse	++	+	-	+	
MV/TV vegetation	++	-	-	-	
AV/PV stenosis	++	+	-	+	
AV/PV vegetation	++	-	-	-	
Pericardial pathology	++	++	-	++	
Coronary origin	+	+	-	++	
Coronary stenosis	-	-	-	++	
Aorta – root/asc	++	++	-	++	
Aorta – arch	+	++	-	++ (Aorta protocol)	
Aorta – descending	-	++	-	++	
Extra-cardiac	-	+	-	++	
Total ++ (%)	16/24 (67%)	14/24 (58%)	1/24 (4%)	10/24 (42%)	
LV, Left ventricular; Sys, systolic; dias, diastolic; wt, wall thickness; RV, right ventricular; LA, left atrial; RA, right atrial; MV/TV, mitral valve/tricuspid valve; AV/PV, aortic valve/pulmonic valve; asc, ascending.

++, should be routinely reported; +, may be routinely reported; -, not routinely reported.

In this month's issue of CASE, there were no normal comprehensive TTE reports. However, there were some excellent CASE reports that we can learn from. Basit et al. expanded our sonic insights with an innovative approach to a patient with an impressive RCA to SVC fistula in Coronary Artery-to-Superior Vena Cava Fistula: Contemporary Role of Phonocardiography in Diagnoses. The authors include 2D and Doppler TTE, high-quality 3D CCT reconstruction, CMR with phase-contrast, invasive angiography and pressure tracings as well as novel spectral frequency display of the murmur from an electronic stethoscope. Their discussion is robust and helps the reader compare and contrast apparent discrepant findings from the different modalities.

Gentile et al., in Characterization of an Aortic Valve Papillary Fibroelastoma Using Three-Dimensional Transillumination Echocardiography, demonstrate the incremental value of photorealistic imaging using 3D TEE transillumination (TI). In one of the more descriptive reports you will ever read, the authors reported their 77-year old patient who presented with an acute stroke and was found to be in atrial fibrillation. Proving their understanding of the value of a comprehensive TEE prior to LAA occlusion device placement, the authors found a papillary fibroelastoma on the aortic valve and cancelled the procedure in place of performing a curative operation. This message alone is worth reiterating globally for all of us that perform TEE studies for this indication. The authors include side-by-side, high-quality images of the PFE as seen with conventional 3D volume-rendered display, gross pathologic excised specimen, and the TI image to help build a strong CASE for the incremental value of TI. They were able to show that the TI echo provided additional characterization of the mass that better matched what was found at surgery (irregular, frond-like, independently mobile borders which shimmered with movement).

Miranda-Segura et al. and Sourour et al. keep up the tradition of including reports on adults and children with congenital heart diseases in essentially every issue of the journal. In Successful Evolution of Atrial Septal Defect Closure in an Elderly Patient With Complex Cardiovascular Disease, these authors remind readers that despite common comorbidities, including significant CAD, ASD closure should offer clinical and hemodynamic improvements. They have excellent images before and 24-months after closure demonstrating the right heart remodeling that transpired. In Anomalous Left Coronary Artery From the Noncoronary Sinus, these authors demonstrate the findings of a dangerous, high-risk anomalous left main coronary. They include TTE, TEE, CCT, and intraoperative correlative images for your comparison. Their description includes how to assess for an intramural course as you carefully inspect coronary size and shape. The surgical images help readers to better appreciate unroofing with marsupialization and resuspension procedures. Adding to the fact that the journal rarely reports normal findings, this young patient had a complicated post-operative course that you must read about.

Lastly, Mathias et al. provide readers with their report as a cautionary tale on a devastating complication after a relatively straight-forward pericardiocentesis. In their report, To Drain or Not to Drain? Pericardial Decompression Syndrome, readers can learn from their illustrative CASE on when to be alert to this possibility, the clinical scenarios that support this pathology, and steps to avoid this complication. In total, this is another must read in CASE.

The next time you read a normal study, think about the value that report gives the managing team. Consider the impact of the type of cardiac study that was reportedly normal (and whether or not the study was comprehensive or limited as well as the quality of the findings) and then, think about the final impression you prepared in your conclusion. If there is an opportunity to better communicate the overall impact of that normal study to the requesting provider, take the time to do so.

And remember, every echo you see today has a teaching point; and every teaching point is a potential new CASE report!
