Interview with William Zoghbi

How time flies. This is the fourth and last interview in our Echo Masterminds series.

This time we have the great pleasure and honor to introduce to you William Zoghbi MD – Past President of the American Society of Echocardiography and President Elect of the American College of Cardiology. William is the director of the Cardiovascular Imaging Institute of the Methodist DeBakey Heart & Vascular Center in Houston and a veritable hot-shot in the field of echo. In this interview, he gave away some truly precious echo gems to the 123sonography community.

So without further ado: William Zoghbi enters the stage......

123sonography: William, from your experience, what are the most common mistakes people make when they perform echo - mistakes that could be easily avoided?

William Zoghbi: There are technical mistakes and there are interpretive mistakes. That’s how I see it.

Talking about the technical mistakes, one of the most common things has to do with the assessment of the left ventricle. One of the largest technical mistakes is foreshortening of the left ventricle. So when that happens, people miss wall motion abnormalities in the apex, apical thrombi and misdiagnose the size of the ventricle. We used to have a lot of mistakes in the assessment of aortic stenosis. That has diminished in frequency. However, the technique of acquisition of good pulse-Doppler signals in the left ventricular outflow tract is still a problem for a lot of people.

Third would be - in my view - the evaluation of mitral regurgitation. Here, I see a lot of technical but also interpretive mistakes. A technical problem occurs when we deal with eccentric jets. In this situation, the sonographer or the physician may not direct the tomographic plane appropriately to address the eccentricity correctly, the structure of the valve and so forth.

123sonography: How important are atypical cut planes in the assessment of eccentric jets in your opinion?

William Zoghbi: I think they are very important. Because you don’t know which scallop is prolapsing or flailing. We have six scallops and they are not in the same tomogram. So once we detect regurgitation, we should try to concentrate on different planes, so we can see where the jet is coming from and how severe it really is.

123sonography: What would be the interpretive mistakes then?

William Zoghbi: One of the most common mistakes is the inconsistency in integrating the different information within a study. I always tell my fellows “think about it, this is the same patient, the same heart – things have to make sense when you put the pieces together”. At times there is apparent conflicting information from different views and you have to be the judge, which information is more reliable. Let’s take the example of mitral regurgitation: the color Doppler evaluation might be different from what the flow evaluation seems to tell us and you have to integrate these findings in order to come up with a solution and a final interpretation.

One other problem is that in their approach, people are not quantitative enough. You need to understand and learn quantitation. In my experience, the more quantitative you are, the better you are in qualitative interpretation.

123sonography: What exactly do you mean by that?

William Zoghbi: I am talking about measurements of size, volume, ejection fraction, thinking about hemodynamics…total stroke volume and these kind of things. When you do that, you will understand things like regurgitation much better. And these are the situations where the majority of our problems exists. You will understand flow dynamics, how much goes through the regurgitant valve, how much goes systemically. And the more you can comprehend the total information that is present in an echocardiogram, the better of an interpreter you will be. So I push my trainees to do quantitation as much as possible. There are many ways to learn that: there are courses, there are videos and other resources. I promise you, you will be a much better interpreter if you learn these basic things.

123sonography: What would you recommend to someone who is just getting started on echocardiography. What are some concrete steps that they could take?

William Zoghbi: Number one I think you need to read, see or listen. There are several ways to acquire information and knowledge through various means. Nowadays there are very innovative platforms of learning echo like your course for example.

Then you have to understand where your deficiencies are and target them specifically. So for example, if I know that my deficiency lies within the evaluation of the left ventricle, then I should focus on acquiring that skill.

Thirdly, I would search in the community for a group or mentor that you could partner with. That could be an echo club or a small society. In Houston, we have a small regional society that meets every four months. You can discuss cases there. So people could send images to their friends and colleagues over the internet or on a disc and discuss them personally or over the web. Living in a vacuum is the worst thing you could do. You have to connect with some sort of community or group of colleagues. At my stage of the game, I still interact with people who I have grown with or were my mentors. I still discuss cases with them, it’s so easy to communicate these days. You are not only doing a service to your patients if you do that, but you are also doing a service to yourself because you are going to grow from that experience.

123sonography: Thank you so much for your time and thank you for all the valuable information you have provided to our community.

William Zoghbi: My pleasure!

Want to find out about the most valuable advice, William ever got from a mentor?
Then watch this video……

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