Interview with Petros Nihoyannopoulos

Interview #3: Petros Nihoyannopoulos - Past President of the European Association of Echocardiography, Professor of Cardiology Imperial College London & YOUR Virtual ECHO Mentor.
We are very honored and happy to have Petros on this interview series. He has taught hundreds if not thousands of people echocardiography. He is a renowned and well-respected figure in the international echo scene. In this interview he will share some of his wisdom with you - the 123sonography community......
123sonography: What are the most common mistakes that you see people commit when they do echo?
Petros Nihoyannopoulos: The most common mistake I would say is that people fail to get a proper parasternal long axis view. This is the A of the long alphabet of echocardiography. That's where everything starts. If you do not get that axis correct, you will end up with wrong measurements, mistaking the wall thickness, under- or overestimate the ventricular dimensions and ultimately making the wrong diagnosis. What can also happen when you fail to obtain a proper parasternal long axis view is that you will give someone a diagnosis that they really don't have. Examples for these diagnoses would be hypertrophic cardiomyopathy or dilated cardiomyopathy.  Simply because your measurements from the parasternal long axis view were wrong. It may sound elementary but I am afraid that this is one of the most common sources of error.
123sonography: Any other mistakes?
Petros Nihoyannopoulos: One other mistake relates to the measurement of the tricuspid velocity using Doppler. A lot of people measure tricuspid velocities as a standard measurement for a mundane echo report. As most of your readers will know, this velocity gives an estimate of right ventricular pressures. So that complements the echo examination in lots of diseases. Typical the tricuspid velocity is between 2.4 to 2.8 meters per second. But the problem with tricuspid regurgitation is that it is often minimal and more often than not, you don't see the maximal velocity. So my advice is, don't imagine where the maximal velocity is - when you don't see it, don't measure it. 
123sonography: What would you recommend to someone who is just getting started to learn echo?
Petros Nihoyannopoulos: This is a very important question. Obviously a good book is essential. There are hundreds of books around but only very few are good. I had this question put forward to me many times during my long career. People were asking me “When are you going to write a book?”. Because I was giving courses, we have the annual Hammersmith echocardiography course end of May. I have been involved with Euroecho. I have been its past president and always devoted to education. A lot of people were asking me “How can I learn? By attending courses?” And I always said, “yes, echo courses are also very important.” And when I was president of the European Association of Echocardiography, we created a large number of courses. But books are also important so after my students put a lot of pressure on me, Joseph Kisslo and myself ended up writing a book to satisfy all students. And because I am a clinician, this book is very much clinically oriented. But you cannot learn echo without understanding very very basic physics. It's all physics really. You need to know three or four formulae so that you can understand how your picture is generated. Only if you understand how the picture is generated will you understand the limitations of the method. Some very good courses like your online course or our on-site course are important and one or two practical clinical books. But what is also really really important is to go to a department where they have experience in teaching. There you will learn by osmosis. You are immersed in the culture, you see pictures around you, people are discussing cases. In my department we have 20 computers around the reporting room and everyone is discussing the views, the mistakes, what would be better, what would be worse….And also, in this environment you will learn the practical issues of image acquisition that I mentioned before. 
So to summarize, you want some good echocardiography courses, some good books on echocardiography with some basic physics and a good department with a lot of experience in teaching. 
123sonogarphy: What would you recommend to someone who does not have access to teachers or departments. How could they go about?
Petros Nihoyannopoulos: We are in the 21st century and the internet is part of our daily life. So there are courses on the internet, there are lectures, there are webinars. Just like the ones you offer. But echo is a practical art. You learn most in a busy department where there are people who can teach. In our department, we have massive experience in teaching. We have master courses and other post-graduate courses for fellows around the world. So I suggest that these people have to find access to a good department that will teach them. At the end of the day, you learn by looking at good echo pictures and from good masters! 
123sonography: Do you want to give some more advice that you would like to share with our readers?
Petros Nihoyannopoulos: If you want to learn echo, you need to be dedicated. Echo is a multimodality method on its own right. I think it is a mistake today to mix echo with CT, MRI, nuclear and all other imaging modalities. Echo is a clinical tool that can be used from the lab to bedside to the catheter lab and the operating theter. It has developed over the years. It is no longer just the Mmode, the parasternal long axis view etc. It is a multimodality method, you have 3D, stress, deformation imaging, interventional echo and so on. You need time and dedication. Reading books and courses linked to a center with experience is my best advice. 
123sonography: Thank you so much for your time!
Petros Nihoyannopoulos: It was a pleasure to talk to you!

Watch this video and hear the best advice Petros ever got from a mentor:

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