Interview Questions for Transthoracic Echocardiography

Standard TTE imaging planes provide different views of the heart’s structure and function. They are crucial for comprehensive assessment. The most commonly used planes include:

• Parasternal Views: These are obtained with the transducer placed on the chest wall next to the sternum. We have long-axis and short-axis views, which provide longitudinal and cross-sectional images of the heart, respectively.
• Apical Views: Obtained with the transducer positioned at the apex of the heart, typically in the left fifth intercostal space. These provide views of the mitral valve and left ventricular outflow tract from an apical perspective. We commonly utilize the four-chamber, two-chamber, and long-axis views from the apex.
• Subcostal Views: The transducer is positioned below the xiphoid process, giving primarily inferior views of the heart. This is particularly useful for assessing the inferior vena cava and the right ventricle.
• Suprasternal Views: With the transducer positioned above the sternum, this provides a view of the great vessels, primarily the aorta and its branches. It’s essential for assessing aortic valve function and the ascending aorta.

Choosing the appropriate plane depends on the specific clinical question. For example, to assess mitral valve function, apical views are essential, while aortic stenosis assessment often requires parasternal and suprasternal views.

Obtaining a parasternal long-axis view involves careful transducer placement and manipulation. Imagine you’re looking at a cross-section of the heart from the side.

1. Position the Patient: The patient lies supine.
2. Transducer Placement: Place the transducer in the third or fourth intercostal space, just left of the sternum. You’ll feel for the ribs to help with accurate placement.
3. Angle Adjustment: Rotate the transducer to obtain the optimal image. You’ll need to adjust both the angle of the transducer and its depth to visualize the left ventricle and mitral valve optimally. The image should show the left ventricle, mitral valve, and aorta in a longitudinal view. This often requires a slight rocking motion to optimize the image.
4. Image Optimization: Adjust the depth and gain to optimize the image quality. You want clear visualization of the endocardial borders.

It takes practice to consistently obtain a clear parasternal long-axis view, and the exact angle will vary slightly based on the patient’s body habitus. High-quality images are crucial for accurate measurements and interpretation. For instance, improper angulation can lead to inaccurate assessment of left ventricular size and function.

Left ventricular systolic function assessment uses various echocardiographic parameters. Think of it as assessing the heart’s pumping power during contraction.

• Ejection Fraction (EF): This is the most commonly used measure. It represents the percentage of blood ejected from the left ventricle with each contraction. A normal EF is typically above 55%, though this can vary slightly based on the method of measurement. We calculate it using the formula: EF = (LVEDV - LVESV) / LVEDV * 100 where LVEDV is left ventricular end-diastolic volume and LVESV is left ventricular end-systolic volume.
• Fractional Shortening (FS): This is a simpler measure, representing the percentage change in left ventricular dimension from end-diastole to end-systole. FS = (LVEDD - LVESD) / LVEDD * 100 where LVEDD is left ventricular end-diastolic diameter and LVESD is left ventricular end-systolic diameter.
• Visual Assessment: Experienced echocardiographers also assess wall thickening, contractility, and the presence of regional wall motion abnormalities. A globally reduced wall thickening suggests a depressed systolic function.

A reduced EF or FS, along with visual abnormalities, indicates impaired systolic function. This is a hallmark of systolic heart failure. Accurate measurement is critical for guiding treatment and prognosis.

Mitral regurgitation, or leakage of blood backward from the left ventricle to the left atrium during systole, has characteristic echocardiographic features. It’s like a leaky valve.

• Color Doppler: Shows a jet of blood flowing from the left ventricle back into the left atrium during systole. The size, shape, and location of the jet help determine the severity of regurgitation.
• Continuous-wave Doppler: Provides a more precise measurement of the regurgitant jet velocity, which is used to calculate the regurgitant fraction.
• Left Atrial Enlargement: Chronic mitral regurgitation leads to volume overload in the left atrium, causing enlargement.
• Left Ventricular Dilation and Hypertrophy: Over time, the left ventricle can dilate and hypertrophy in response to the increased volume and pressure.
• Pulmonary Hypertension: In severe cases, the increased left atrial pressure can lead to pulmonary hypertension. We can assess this by measuring the pulmonary artery pressures.

Combining these findings helps determine the severity of mitral regurgitation and guide treatment decisions. The severity is often graded based on the size of the regurgitant jet and the resulting left atrial and ventricular changes.

Left atrial size is a crucial parameter in assessing cardiac function. Think of it as the atrium’s capacity. We measure it in different views.

The most common method is measuring the left atrial diameter in the apical four-chamber view. We measure the largest dimension of the left atrium perpendicular to the left atrial appendage. The measurement is made from the far wall of the left atrium to the opposite wall, excluding the appendage. Normal values vary slightly based on body surface area and the specific methodology but generally remain under 40mm.

Alternatively, we can also estimate Left Atrial Volume (LAV) using more advanced techniques involving planimetry. These methods require more detailed measurements and calculations, but they provide a more comprehensive assessment of atrial size. However, the simple linear measurement from the apical four-chamber view is commonly used as a rapid and reasonably accurate assessment.

Diastolic and systolic heart failure are two distinct types of heart failure, each reflecting a different aspect of cardiac dysfunction. Think of them as the heart failing to fill properly (diastolic) or pump effectively (systolic).

• Systolic Heart Failure: Characterized by impaired ability of the heart to pump blood effectively. The left ventricle is unable to contract forcefully enough to eject sufficient blood. This leads to a reduced ejection fraction and symptoms such as shortness of breath, fatigue, and edema. Echocardiography shows reduced EF, often with decreased wall motion, and potentially left ventricular dilation.
• Diastolic Heart Failure: Characterized by the inability of the heart to relax and fill properly during diastole. The left ventricle is stiff and can’t accommodate the normal amount of blood. This leads to high filling pressures and symptoms such as shortness of breath, particularly on exertion. Echocardiography shows normal or near-normal EF but with impaired relaxation, increased filling pressures (seen as elevated E/e’ ratio), and often left atrial enlargement.

Both conditions often lead to pulmonary congestion and reduced exercise capacity. However, the underlying mechanism and treatment strategies differ significantly.

Aortic stenosis, or narrowing of the aortic valve, has distinctive echocardiographic findings. It’s like a partially blocked pipe reducing blood flow.

• Thickened and Calcified Valve: The aortic valve leaflets may appear thickened, calcified, and immobile on the echocardiogram, often reducing the opening of the valve.
• Reduced Aortic Valve Area (AVA): The most crucial measurement is the AVA, which indicates the severity of the stenosis. A reduced AVA correlates with higher pressure gradients across the valve.
• Increased Pressure Gradient: The Doppler echocardiogram shows a high-velocity jet across the stenotic valve, reflecting the increased pressure difference between the left ventricle and the aorta.
• Left Ventricular Hypertrophy: The left ventricle works harder to overcome the increased resistance. This results in concentric left ventricular hypertrophy, visible as thickening of the left ventricular walls.
• Left Atrial Enlargement: In advanced cases, the increased left ventricular pressure can lead to left atrial enlargement.

These findings are vital for assessing the severity of aortic stenosis, guiding treatment decisions, and monitoring disease progression. Severe aortic stenosis is a life-threatening condition that requires prompt intervention.

Identifying pericardial effusion on a transthoracic echocardiogram (TTE) involves looking for an anechoic (fluid-filled) space between the epicardium (outer layer of the heart) and the pericardium (sac surrounding the heart). We assess the amount and location of the effusion. A small effusion may be difficult to detect, appearing as a subtle separation between the layers. Larger effusions are more readily apparent, often appearing as a clear, black space around the heart in different views. We often use the apical four-chamber, subcostal, and parasternal views to visualize the effusion completely.

Think of it like this: imagine a balloon (the heart) inside another balloon (the pericardium). A pericardial effusion is like extra fluid between those two balloons. The more fluid there is, the easier it is to see the separation.

We also assess for hemodynamic consequences such as right atrial and ventricular collapse (due to increased pressure), which can point towards a significant effusion needing urgent intervention. We also look at the presence of diastolic collapse of the right atrium and ventricle which would be a sign of a large pericardial effusion.

TTE, while a powerful tool, has its limitations. One major limitation is the dependence on the acoustic window – bone and air interfere with ultrasound waves, making it difficult to obtain clear images in patients with obesity, lung disease (e.g., COPD), or significant air in the pleural space. Also, image quality can be affected by patient factors such as body habitus, and the skill of the sonographer is crucial in obtaining optimal images. Moreover, TTE can struggle to visualize structures behind the sternum. Furthermore, small lesions or subtle abnormalities might be missed, potentially requiring other imaging modalities such as transesophageal echocardiography (TEE) for a more comprehensive evaluation.

For example, visualizing the left atrial appendage can be challenging in certain patients, while TEE gives a far clearer view.

Doppler echocardiography utilizes the Doppler effect – the change in frequency of a wave (in this case, ultrasound) due to relative motion between the source and the receiver. In echocardiography, the ultrasound beam is directed at moving blood cells. The reflected waves change frequency depending on the speed and direction of blood flow. This frequency shift is then analyzed to determine the velocity and direction of blood flow within the heart. It’s crucial in assessing valve function, detecting shunts, and measuring pressures. We use different Doppler modalities like pulsed-wave, continuous-wave, and color Doppler to obtain comprehensive flow information.

Imagine a police car siren: as it approaches, the pitch is higher (increased frequency), and as it moves away, the pitch is lower (decreased frequency). The Doppler effect in echocardiography works on the same principle.

• Pulsed-wave Doppler provides velocity information at a specific location.
• Continuous-wave Doppler can measure very high velocities but doesn’t provide precise location information.
• Color Doppler provides a visual representation of flow direction and velocity, allowing for quick identification of areas of abnormal flow.

Assessing right ventricular (RV) function on TTE involves evaluating several parameters. We begin with visualization of the RV using the apical four-chamber, parasternal long axis, and parasternal short axis views. We assess RV size and shape: an enlarged RV may suggest volume overload or pressure overload. We then look at RV systolic function by measuring the tricuspid annular plane systolic excursion (TAPSE) and RV fractional area change (FAC) which helps assess the contractility. RV inflow and outflow tract velocities are measured using Doppler to assess for any obstruction. Finally, we assess RV pressure indirectly via estimation of tricuspid regurgitation pressure gradient which reflects RV systolic pressure.

For instance, a reduced TAPSE or FAC indicates impaired RV systolic function, a common finding in pulmonary hypertension.

Echocardiographic findings in pulmonary hypertension (PH) are varied and depend on the severity and cause. Common findings include right ventricular dilation and hypertrophy (enlargement of the RV muscle), increased right atrial pressure, tricuspid regurgitation with elevated pressure gradient (indirect measure of RV pressure), and reduced RV systolic function (decreased TAPSE and FAC). Pulmonary artery dilation and increased pulmonary artery pressure are usually directly visualized. In advanced disease, RV failure with tricuspid regurgitation, and even signs of right-sided heart failure can be seen.

It’s important to note that echocardiography alone may not always be enough to diagnose PH definitively, and further investigations such as cardiac catheterization may be necessary.

TTE can detect various cardiac shunts, either left-to-right or right-to-left. Left-to-right shunts involve blood flowing from the higher-pressure left side of the heart to the lower-pressure right side. Examples include atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA). These are usually detected by color Doppler, showing abnormal flow across the septal defect or ductus. Right-to-left shunts, where blood flows from the right to the left side, are more serious as they cause mixing of oxygenated and deoxygenated blood (cyanosis). These can be seen in tetralogy of Fallot, transposition of great arteries, and other complex congenital heart diseases, where we might see abnormal flow patterns and altered chamber sizes.

For example, an ASD will often show a jet of blood flowing from the left atrium to the right atrium during diastole on color Doppler.

Differentiating constrictive pericarditis from restrictive cardiomyopathy on TTE can be challenging, requiring careful attention to detail. Both conditions present with diastolic dysfunction (impaired filling of the ventricles). However, key differences exist. In constrictive pericarditis, the hallmark is impaired diastolic filling due to the restrictive effect of the thickened pericardium. Echocardiography reveals early diastolic collapse of the right atrium and ventricle, and sometimes even the left ventricle. Pericardial thickening might be directly visualized. In restrictive cardiomyopathy, diastolic dysfunction is due to impaired myocardial relaxation or increased myocardial stiffness. Echocardiography will show abnormalities in ventricular relaxation and filling patterns without the characteristic early diastolic collapse seen in constrictive pericarditis. We often need additional clinical information and sometimes even cardiac catheterization to make the definitive diagnosis.

Imagine two scenarios: in constrictive pericarditis, the heart is squeezed by a tight band (the thickened pericardium), while in restrictive cardiomyopathy, the heart muscle itself is stiff and inflexible.

Transthoracic echocardiography (TTE) plays a crucial role in assessing valvular heart disease by providing a comprehensive, non-invasive visualization of the heart valves. It allows us to evaluate valve structure, function, and hemodynamics. We can assess for stenosis (narrowing) or regurgitation (leakage) in each valve – the aortic, mitral, tricuspid, and pulmonary valves.

For example, in aortic stenosis, TTE can show the thickening and calcification of the aortic valve leaflets, measure the valve area (to quantify the severity of stenosis), and assess the pressure gradient across the valve. Similarly, in mitral regurgitation, TTE can demonstrate the extent of valve leaflet prolapse or dysfunction, assess the volume of regurgitant flow, and determine the impact on left atrial and ventricular function. We use various measurements like valve orifice area, peak velocity, and regurgitant fraction to assess the severity of valvular dysfunction.

TTE is also vital in guiding treatment decisions, helping determine the need for surgical or transcatheter intervention and monitoring the effectiveness of these interventions. The images provide a detailed assessment that is far superior to simply listening to the heart with a stethoscope.

Indications for a TTE are numerous and depend on the clinical context. Some common reasons include:

• Suspected valvular heart disease: This includes symptoms like shortness of breath, chest pain, palpitations, or a heart murmur detected during physical examination.
• Evaluation of heart failure: TTE helps assess left and right ventricular function, ejection fraction, and valve function to determine the cause and severity of heart failure.
• Assessment of cardiomyopathies: TTE is crucial for identifying and characterizing various cardiomyopathies, including dilated, hypertrophic, and restrictive cardiomyopathies.
• Detection of pericardial effusion or cardiac tamponade: TTE can quickly visualize fluid around the heart and assess its hemodynamic significance.
• Pre-operative cardiac evaluation: TTE helps assess cardiac function before major surgeries to determine surgical risk.
• Follow-up of known cardiac disease: TTE is vital for monitoring disease progression and the effectiveness of treatment in patients with established cardiac conditions.
• Evaluation of suspected congenital heart disease: In some cases, TTE can provide valuable information about congenital heart defects.

Essentially, any patient with symptoms or findings suggestive of heart disease might benefit from a TTE.

Interpreting a TTE report requires a systematic approach. It’s not just about looking at pretty pictures; it’s about understanding the clinical context and correlating the images with the patient’s symptoms and history.

I typically start by reviewing the patient’s demographics and clinical presentation. Then, I meticulously assess:

• Left Ventricular Function: Ejection fraction (EF), wall thickness, systolic and diastolic function (assessing for hypertrophy, dilation, or impaired relaxation).
• Right Ventricular Function: Size, shape, systolic and diastolic function, and pressure estimation.
• Valve Function: Assessment of each valve for stenosis and regurgitation, including quantification of severity. This often involves measurements of valve areas, pressure gradients, and regurgitant fractions.
• Chambers Size & Volumes: Left and right atrial and ventricular dimensions and volumes are crucial in determining the presence of chamber enlargement.
• Pericardium: Evaluation for the presence of pericardial effusion or cardiac tamponade.
• Aorta: Measurement of the aortic root and ascending aorta to rule out aneurysms or dissections.

The report integrates all these findings into a concise summary, providing a diagnosis and recommendations for further management. It is a collaborative process involving the cardiologist, the sonographer who performed the test, and the patient’s physician.

TTE, despite its non-invasiveness, is susceptible to various artifacts. These are essentially image distortions that can mimic pathology or obscure true findings. Some common artifacts include:

• Acoustic shadowing: Caused by dense structures (e.g., calcifications) that attenuate the ultrasound beam, resulting in a shadow behind the structure. This can obscure underlying anatomy.
• Acoustic enhancement: The opposite of shadowing; fluid-filled structures can enhance the signal behind them, creating a brighter area.
• Reverberation: Multiple reflections of the ultrasound beam between two strong reflectors (e.g., air-tissue interfaces), creating multiple parallel lines.
• Mirror image: A false image created by reflection of the ultrasound beam from a strong reflector, often seen near the diaphragm.
• Ring-down artifact: Continuous signal from air bubbles or gas within the cardiac chambers.

Addressing these artifacts involves optimizing the technique: adjusting the gain, frequency, depth, and using different imaging windows or transducer positions. Experience is key in recognizing and differentiating artifacts from true pathology. Knowing the typical locations and appearances of various artifacts can prevent misinterpretations.

Transducer selection for TTE is crucial for optimizing image quality. Different transducers have different frequencies and imaging capabilities.

• 2.5-5 MHz transducers: Commonly used for adult patients, providing a balance between penetration depth and spatial resolution. These are frequently used for standard views.
• Higher frequency transducers (7-10 MHz): Offer superior spatial resolution but at the cost of penetration depth. They are more suitable for visualizing smaller structures and superficial details. Useful for pediatric patients or when high-resolution images are needed.
• Phased array transducers: Offer broad imaging fields and excellent versatility. These are commonly used for apical, subcostal, and suprasternal views.
• Sector transducers: Are useful for obtaining images from different angles by sweeping the beam across the area of interest.

The choice of transducer depends on the patient’s size, the specific views required, and the clinical question being addressed. For example, a high-frequency transducer is ideal for visualizing mitral valve leaflets in detail, while a lower frequency transducer may be preferred for deep structures in obese patients.

Optimizing image quality in TTE is paramount for accurate interpretation. Several factors influence image quality.

• Proper transducer placement and angulation: Achieving optimal acoustic windows requires meticulous attention to transducer placement and manipulation. This involves careful adjustment of the transducer’s position and angle to get the desired views and avoid obstacles such as ribs or lung tissue.
• Gain adjustment: Appropriate gain settings ensure optimal signal amplification without excessive noise. This needs to be adjusted for different areas and depths.
• Depth adjustment: Appropriate depth settings ensure that the entire structure of interest is visualized. Setting this correctly minimizes image clutter and ensures complete imaging.
• Frequency selection: The choice of transducer frequency significantly impacts image resolution and penetration. Higher frequency transducers provide better resolution but less penetration.
• Use of harmonics: Using harmonic imaging can enhance image quality by suppressing noise and improving contrast resolution.
• Patient positioning and respiration: Patient cooperation and proper positioning and breathing instructions are essential for optimal image quality. Deep inspiration may be required for certain views.

Careful attention to all these factors, combined with operator skill and experience, is crucial for high-quality images necessary for accurate diagnosis.

Safety precautions during a TTE exam are essential to minimize any potential risks. Although TTE is considered a safe procedure, it’s important to be vigilant.

• Verify patient identity and allergies: Ensure that the correct patient is being examined and check for any allergies to ultrasound gel.
• Proper use of ultrasound gel: Use a sufficient amount of ultrasound gel to ensure good acoustic coupling and to prevent discomfort from friction. Make sure the gel is hypoallergenic.
• Explain the procedure to the patient: Explain the procedure to the patient in clear, simple terms and address any concerns they may have.
• Monitor the patient during the exam: Closely monitor the patient for any adverse effects, such as discomfort or changes in vital signs.
• Appropriate infection control measures: Strict adherence to infection control protocols is essential to prevent cross-contamination. This includes proper hand hygiene, use of sterile gloves, and appropriate disinfection of the transducer.
• Awareness of potential risks: While rare, potential risks include discomfort, skin irritation from the gel, and the potential for rare complications associated with the procedure. These must be disclosed to the patient beforehand.

By adhering to these safety measures, we can ensure patient safety and minimize potential risks during the TTE exam.

Patient anxiety during a TTE is common, as the procedure involves a chest probe and can feel intrusive. My approach is multifaceted, prioritizing open communication and a calming demeanor. I begin by explaining the procedure in simple terms, focusing on what the patient will feel and see. I use analogies to demystify the process; for example, I might describe the ultrasound gel as simply a lubricant that helps the probe glide smoothly. I answer all their questions thoroughly and patiently, addressing any concerns about pain or discomfort (emphasizing that the exam is generally painless, just a little pressure). I also offer reassurance and support, letting them know they can stop the exam at any time if they feel uncomfortable. If necessary, I may offer distraction techniques like engaging in light conversation or offering them music to listen to. In cases of significant anxiety, I collaborate with the referring physician or a healthcare professional specializing in anxiety management to provide additional support before or during the exam.

TTE is generally a very safe procedure, but like any medical exam, potential complications exist, albeit rare. The most common is minor discomfort or bruising at the probe site. This is usually transient and easily managed with ice packs. Very rarely, patients might experience a slight increase in heart rate or blood pressure during the examination, but this is usually self-limiting. In extremely rare cases, more serious complications such as pneumothorax (collapsed lung) can occur, particularly in patients with underlying lung disease. This is why a thorough patient history and appropriate risk assessment are crucial before initiating the procedure. Other extremely rare complications include arrhythmias triggered by the exam. For this reason, constant monitoring of the patient’s vital signs during the exam is paramount. It’s important to emphasize that these serious complications are exceedingly rare, and proper technique and patient monitoring significantly mitigate the risks.

Throughout my career, I’ve had extensive experience with a wide range of TTE equipment, from basic analog machines to the latest high-end digital systems with advanced features like strain imaging and 3D capabilities. My experience includes working with various manufacturers’ systems, and I’m proficient in utilizing their specific features and functionalities. This includes understanding how to optimize image acquisition parameters, adjust gain and focus, and apply various imaging modalities such as M-mode, 2D, Doppler, and tissue Doppler imaging to optimally visualize different cardiac structures and functions. For example, using a high-end system with speckle tracking echocardiography (STE) allows for more precise quantification of left ventricular function, providing more nuanced diagnostic information than older systems. I’m adept at troubleshooting technical issues and ensuring the equipment is operating optimally, leading to accurate and high-quality images. Adapting to different equipment is a key skill, ensuring consistent high-quality assessments across various clinical settings.

My experience encompasses a diverse range of patient populations, including neonates, pediatrics, adults, and geriatrics. Each age group presents unique challenges and requires tailored approaches. For instance, examining neonates requires specialized probes and techniques due to their small size and delicate anatomy. Geriatric patients might have various comorbidities influencing the examination, requiring careful consideration of their overall health status. I’ve worked with patients suffering from a wide spectrum of cardiac conditions, ranging from simple valvular diseases to complex congenital heart defects and post-surgical patients, allowing me to adapt my techniques and interpret the results within the context of each individual’s unique clinical picture. Understanding the specific challenges presented by each population is crucial for obtaining high-quality images and making accurate diagnoses.

Maintaining quality control in TTE is paramount for accurate diagnoses. My approach involves a multi-pronged strategy. Firstly, regular quality checks on the equipment are essential, including daily testing of the machine’s functionality, probe calibration, and image quality assessment using phantom testing. Secondly, adherence to standardized protocols for image acquisition and analysis is critical. We use established guidelines to ensure consistency in image acquisition and interpretation. Thirdly, continuous professional development is essential, staying updated with the latest advancements in echocardiography through continuing medical education (CME) courses and participation in professional organizations. Finally, regular internal and external quality assurance programs help monitor the quality and consistency of our exams and provide feedback for improvement. This iterative process ensures high quality, standardized results. We also maintain a meticulous record keeping system to easily track and review past exams and monitor consistency.

TTE findings are central to patient care. The images and measurements provide crucial information to guide diagnosis, treatment planning, and monitoring of cardiac conditions. For example, detecting left ventricular hypertrophy through TTE can aid in diagnosing hypertensive heart disease. Measuring ejection fraction is crucial in assessing the severity of heart failure. Identifying valvular abnormalities helps in planning for interventions like valve replacement or repair. I actively participate in multidisciplinary team meetings, sharing my findings and collaborating with cardiologists, surgeons, and other healthcare professionals to formulate the best treatment plan for each patient. I also provide follow-up reports, explaining the findings in clear, understandable language for both the patient and referring physician. In essence, I utilize TTE to contribute to a comprehensive and effective approach to patient care.

Handling difficult or challenging cases requires a systematic approach. First, I carefully review the patient’s clinical history and any prior echocardiograms. I then determine if additional views or imaging modalities are necessary to optimize image quality and obtain a clearer picture of the cardiac anatomy and function. This might include using specialized probes, adjusting the imaging parameters, or employing advanced techniques like contrast echocardiography or 3D echocardiography. If I encounter significant challenges in obtaining adequate images, I consult with senior colleagues or experts in echocardiography to discuss the case and explore alternative strategies. Documentation of the challenges encountered, and the rationale behind the chosen approach, is meticulously documented. In some cases, I might recommend additional tests, such as cardiac magnetic resonance imaging (CMRI) to provide complementary information. The goal is always to obtain the best possible information to inform patient management, even if it means collaborating with other specialists or employing alternative imaging techniques. Transparency and a collaborative approach are essential in handling these complex cases.