It is hard to believe that with the January 2012 issue of JASE , we will reach a milestone. This journal now is 25 years old. As with life in general, it’s amazing how quickly time passes. Celebrating a milestone is always bittersweet. It reminds all of us how quickly time goes by. It also offers an opportunity to stop and reflect backward and look forward. The journal and the field of echocardiography have undergone dramatic transformations over the past 25 years. One of the few advances for which I personally take some credit is that both the field and the journal are now digital. The Indiana University echocardiography lab went digital in 1984. From 1984 to 1991, the storage of echocardiograms was on floppy disks. A digital network went live on July 1, 1991. I am proud to say that JASE was one of the first imaging journals to have its case reports in a digital format, permitting readers to view moving images.

There have been other developments that affected both the field of echocardiography and the Journal of the American Society of Echocardiography . Both the field and the journal have had to deal with significant competition over the past 25 years. Echocardiography is now competing with dramatic new imaging technologies in the form of cardiac computed tomography (CT) and magnetic resonance imaging (MRI). JASE also has had new competition from other imaging journals as well as dedicated echocardiography journals. With the introduction of competition there will always be pessimists who begin to question the status and viability of both the field and the journal. There was considerable concern that the European Journal of Echocardiography might have a devastating impact on JASE . Many of our submissions came from overseas, especially Europe. After we seemed to survive that competition, the next onslaught came from imaging journals that were spinoffs from the Journal of the American College of Cardiology and Circulation . Again, despite the introduction of these new publications, JASE continues to thrive. Its impact factor and the number of submissions are still growing despite the presence of these competing journals.

The increasing use of cardiac CT and MRI, together with the ongoing competition from nuclear cardiology and positron emission tomographic imaging, has been a major concern to those involved with echocardiography. There are many who now feel that echocardiography should be lumped together with the other technologies into one large field of cardiac imaging. Thus, they feel that both the American Society of Echocardiography and JASE should include all cardiovascular imaging and not be limited to cardiac ultrasound. There is no question that cardiology fellows do not want their training to be limited to only echocardiography. They want to be exposed to all imaging modalities. As a result of these developments, there is a serious question as to whether an organization and a journal dedicated solely to echocardiography are still relevant.

The ultimate future of cardiac imaging is still unknown. All of the techniques continue to evolve. Some very dramatic economic changes are upon us and will have an increasing impact on how we use our imaging technologies. Cardiac CT and MRI are advancing at a fairly rapid pace. Although they both have limitations, efforts to overcome these limitations as quickly as possible are ongoing. The aim with CT is to obtain more information with less radiation, and with cardiac MRI, the goal is to overcome the inability to examine people with cardiac devices such as pacemakers and defibrillators. Although many consider echocardiography to be a mature technique with relatively few important advances, that couldn’t be further from the truth. There are actually too many echocardiographic advances being evaluated at this time. Those of us using echocardiography routinely don’t know which of, and when, these developments will be introduced into our practice. For example, one area that is currently being discussed is the role of handheld devices, which are not much bigger than an iPhone. From a symbolic point of view, the size and versatility of an iPhone-sized ultrasound device are in stark contrast to computed tomographic and MRI instruments.

Because no one can accurately predict the future, because of the rapid changes in technology and medical economics, I will take the prerogative of giving my personal opinion and prediction. My point of view is that echocardiography is sufficiently unique that it should be and will continue to be an independent imaging entity and does not need, nor should it be part of, a general cardiac imaging practice. Echocardiography differs from CT, MRI, and even nuclear imaging in many ways. First of all, philosophically, diagnostic ultrasound is a natural imaging technique. Certain mammals, including bats and aquatic mammals, use sonic imaging as a natural way of sensing their environment. I am not aware of any animal that uses any form of ionizing radiation or magnetic imaging for similar purposes. When some people indicate that echocardiography is mature and there is nothing more that can be developed, I always remind them that we are still not as good as the bat. There is still much to be learned as to how this animal is able to function in such an exquisitely complex way using sonic imaging alone. Whenever someone reminds me that ultrasonic imaging is limited by the speed of sound, I always say, “Don’t ever say that to an ultrasonic engineer.” It is amazing how these engineers fool the laws of physics and are able to obtain a voluminous amount of information using a modality as slow as sound. I can’t tell you how often I was told that we will never have real-time dimensional echocardiography because of the slow speed of sound. For that matter, even two-dimensional color Doppler defies the laws of physics with regard to the velocity of sound.

Over the past five decades, I have been constantly asked to predict future echocardiographic developments. I always felt that there would be some way of recording real-time three-dimensional echocardiography. However, did I predict harmonic imaging or two-dimensional color Doppler? The answer is no. I certainly did not predict speckle tracking as one of the major advances in analyzing echocardiograms. In fact, speckle tracking is probably the most important advance in ultrasonic imaging since color Doppler. The medical-economic issues facing the United States as well everywhere else in the world will make “cost-effectiveness” increasingly important in the choice of medical imaging. Diagnostic ultrasound has a major advantage in this area. To take full advantage of its capabilities, the ultrasonic examination must be definitive and not viewed as a “screening” examination performed before a more expensive test. Physicians have historically liked to use the word “complementary” to justify performing multiple examinations to make a diagnosis. That approach will no longer be acceptable. Thus, there will be more pressure on echocardiography to be less subjective and more quantitative. Speckle tracking has the potential of meeting this need.

Besides the technical, versatility, and economic differences between echocardiography and other imaging modalities, there are significant differences in how the imaging techniques are used. First of all, echocardiography is established as an integral part of the practice of clinical cardiology. Together with electrocardiography, it is a fundamental component of a cardiac evaluation. Proctor Harvey, one of the foremost clinical cardiologists, always used the five fingers to represent the components of the cardiac workup, which when working together make a fist that provides the ability to make a proper diagnosis. Although he raised this concept before the widespread use of echocardiography, he certainly would now include echocardiography as one of the fingers. It is very unlikely that one of those fingers will ever be CT or cardiac MRI.

The everyday practice of echocardiography is clearly in the hands of the clinician, not the imager. Virtually every practicing clinical cardiologist is expected to be, and should be, an expert in the field of echocardiography. They may not be investigators or promoters of the latest advances, but they should be able to use the latest technology that is available to manage their individual patients. Some cardiologists who spend their time primarily in the interventional or electrophysiologic laboratory likely won’t have the time or inclination to keep up with the latest diagnostic echocardiographic techniques and may not formally interpret echocardiograms. However, I am certain that they will all be able to interpret and review echocardiograms on their own patients, which is relatively easy to do now that echocardiography is in the digital age, and these images are readily available virtually everywhere.

Although many noncardiologists are appropriately using echocardiography, this activity is not under the domain of radiology, which at times makes claims to “all imaging.” It was clearly established many years ago that echocardiography is unique and doesn’t belong in the general realm of “imaging,” which is sometimes considered a synonym for “radiology.” Those noncardiologists who use echocardiography in their areas of expertise, such as cardiac anesthesiologists in the operating room, are using it appropriately and well. Radiologists have never had any inclination to be in the operating room to supervise transesophageal echocardiographic studies. Because there are relatively inexpensive and mobile echocardiographic devices, there is no economic reason to have to share equipment with another department such as radiology. This is not the case with very expensive computed tomographic and MRI devices. Even nuclear cardiology is still a battleground between cardiology and radiology as a result of both historic as well as territorial claims. This problem occurs rarely, if at all, with echocardiography.

Echocardiography will continue to be dominant in clinical cardiology, partially because it requires a fundamental understanding of cardiac anatomy, pathology, physiology, hemodynamics, and therapy, all of which are the components of the everyday practice of clinical cardiology. I have always defined myself as a clinical cardiologist with a special interest in echocardiography. I have been offered an academic position in radiology (at likely higher pay), but I have always refused because I am not an “imager.” I don’t believe I do anything that is “radiologic.” Cardiology is by definition the study of the heart. Echocardiography is a useful tool to carry out this study.

Thus, for all the above reasons, I am convinced that echocardiography should and will remain a distinct entity and should be supported by an organization and a journal that are dedicated solely to echocardiography. I would also like to emphasize that echocardiography is by no means a mature and unchanging technology. For example, three-dimensional echocardiography and speckle tracking are still under active investigation and development. Neither technique is fully implemented in today’s practice of echocardiography. There is every indication, however, that they both will be components of everyday echocardiography. Parts of these technologies, such as transesophageal three-dimensional echocardiography, are already being widely used. It is also highly probable that speckle tracking will merge with three-dimensional echocardiography, thus enhancing the acceptance of both technologies. Contrast echocardiography has been around for multiple decades and is still evolving. One of these days, the US Food and Drug Administration will finally come to its senses and approve contrast for myocardial perfusion. Once that is approved, there is no question that this application will be very competitive with nuclear perfusion and will expand the use of ultrasonic examinations.

I have said on many occasions that echocardiography will not be fully developed in my lifetime. As I am not getting any younger, this prophecy is becoming more and more likely to come true. So I am happy to be a part of the celebration of the 25th anniversary of the Journal of the American Society of Echocardiography . The history of the past 25 years has been spectacular, and as ultrasonic engineers continue to amaze me, the future for the next 25 years should be equally as fruitful and exciting.