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Echocardiography,Dopplercardiography,
Physical principles,
Indications, Limitations,Normal values, The reporting
format of Echo, Diastolic andsystolic dysfunction
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What is an Echo?
Use of ultra sound to
eamine the heart
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What are types of
Echocardiography?
! mode echo
" DI!EN#I$N%L E&'$(
Transthoracic Echo) transducer directly on the
chest *all Transesophageal Echo) pro+e placed into the
esophagus and stomach
#tress echocardiography) Tran thoracic echo atrest and post stress or eercise
$thers( &ontrast, )D, -)D
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What does an Echo do?
&ham+er si.e,
thic/ness and function
%ssess all cardiac
valves
%ssess hemodynamics
&ongenital heart
diseases #ome etracardiac
shunts
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Who can perform it?
$+viously Echocardiologists as categori.ed
+y %#E 0%merican #ociety of
Echocardiography1
&ardiac #onographers *ith proper and
formal training in the field
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%dvantages of Echocardiography
Non)invasive 0TTE1
%ccurate assessment of structurala+normalities such as valvular dysfunction
and L2'
No ioni.ing radiation
Porta+le
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Limitations of the Echo
Ina+ility to o+tain high 3uality picturesespecially *ith the transthoracic approach
Diagnostic accuracy is operator )dependent
Epensive may not +e afforda+le for all4 'i tech diagnostics
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Ultrasound production
#ound is a distur+ance propagating in amaterial4
Each sound has a characteristic fre3uencyand intensity 0'., 5'., !'.14
#ound higher than "65'. is not perceived+y the human ear and is called ultra sound4
2elocity of sound in cardiac tissueis78-6m9s
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Pie.oelectric effect
Ultra sound results from the property of
certain crystals li/e +arium titanate to
transform electrical oscillations into
mechanical oscillations4
The same crystals can also act as
ultrasound receivers 0mechanical :
electrical1
Ultrasound *aves may +e reflected, or
a+sor+ed or refracted as they traverse
tissues
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Physics and Instrumentation ctd.
I. Transducer containing Piezoelectric
Element Converts electrical to Ultrasound beam(in millions of cycles per second
II. !hen "irected to#ards the heart re$ectedUltrasound (echo is converted bac% to
energy by the Piezoelectricelement #hich permits
Construction of an image using&
Intensity of Echoes (fre'uencynes density of di)erent tissue
Interfaces in the heart
Time ta%en for echoes to arrive*ac% to the transducer i.e. distan
+rom the transducer
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Indications for echocardiography
#uspected heart failure or at high ris/ ofdeveloping it, *ho have not yet had an echoscan
#creening of those *ith esta+lished ischaemicheart disease, i4e4 a past history of( – myocardial infarction, – atrial fi+rillation or – re)vascularisation, *ho have not had and echo
scan
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!urmurs of un/no*n cause Investigation of shortness of +reath *ho
have an a+normal E&; #creening relatives of patients *ith
cardiomyopathies #ymptoms and signs related to cardiac
etiology e4g4 DI< on eertion, murmur4 Initial evaluation of /no*n or suspected
heart failure and re)evaluation if there is achange in clinical status
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=outine evaluation of patients *ith valvular
stenoses or regurgitation4
Evaluating valvular heart disease4 evaluation of suspected infective
endocarditis4
Prior testing suggesting heart disease> suchas a &= *ith cardiomegaly, an elevation of
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5no*n or suspected adult congenitaldisease4
#ustained supraventricular and ventriculartachycardia4
Evaluation of myocardial ischemia 9infarction
Evaluation of complications of myocardialischemia9 infarction> reduced e@ectionfraction, shoc/ etc
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Aor evaluation of suspected or /no*npulmonary hypertension> right ventricularfunction and estimation of pulmonary artery
pressure Evaluation of suspected cardomyopathy)
genetic restrictive or infiltrative and
screening for inherited cardiomyopathy infirst degree relatives of patients *ithinherited cardiomyopathy
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Evaluation of aortic disease e4g syphilitic
aortitis or marfanBs syndrome
Initial evaluation of suspected hypertensiveheart disease
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Patient preparation
;ive a +rief and simple
eplanation to patient
Patient should +e striped
to the *aist and as/ed tolie flat on the couch4
Aemale patients could
*ear a go*n *hich opens
to the front4
E&; leads should +e
attached to the patient – Time cardiac events
– $+serve the heart rate
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Echo *indo*s
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Echo planes
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Echo vie*s
Parasternal vei*s
: Long and #hort aes
%pical vie*s
: - &ham+er vie*
: 8 &ham+er vie*
: Long ais 0" &ham+er1
#u+costal vie*s
: Long and short aes #uprasternal vie*s
: Long and short aes
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Parasternal Long %is
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The parasternal exam
Transducer in the 3rd or 4th intercostal space – Long axis view of the left ventricle
Transducer groove facing the right shoulder Visualise;
Long ais of the L2 and L2$T4 !otion of L2 anteroseptal and posterolateral *all
0 recogni.e any hypo/inesis, a/inesis ordys/inesis 1
%ortic root and aortic valve leaflets4 L% cavity !2> anterior and posterior leaflets, chordal and
papillary muscle attachments
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!easure> L2 dimensions in end)diastole( interventricular
septum, cavity, posterior *all
%ortic root diameter %trial dimensions
With colour visuali.e( =egurgitation of mitral and aortic valves
Estimate 0eye)+all1( L2 systolic function
=2 systolic function
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The short axis view; Perpendicular to the long axis views
*ith groove facing the left shoulder . 2ie*+y inferior or superior angulation of thepro+e>
The mitral valve level
The aortic valve level The papillary muscle level The ape level
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Parasternal #hort %is : Papillary
!uscle Level
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Parasternal #hort %is : %ortic
2alve Level
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The apical position
Patient in the lateral decu+itus position4 pical four cham!er The transducer is placed at the apical impulse *ith the
notch facing up to display the left ventricle on the right4
=otate until all four cham+ers are seen *ith the tricuspidand mitral valve in full ecursion4 View> atrial septum %pply colour flo* to T2, !2 and assess for any
regurgitation
"easure L% volumes, L2 volumes !easure mitral inflo* pulmonary vein mitral annular
velocities 0tissue dopplers1 !easure T2 velocities
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%pical Aour &ham+er
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pical two cham!er; =otate the transducer cloc/*ise to C6 degrees from the
apical four cham+er vie* anterior myocardial *all motion4
inferior myocardial *all motion4 pical three cham!er; =otate the transducer anti)cloc/*ise to C6 degrees from
the apical four)cham+er vie* 0parasternal long aisrecorded from the ais1 to analyse the anterior and inferior
myocardial *all motion4 View> %ortic outflo* Inferolateral and anteroseptal *all motion4
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$ther apical cham+er vie*s
pical # cham!er view pical # cham!er view
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$u!costal views
Transducer in midline, perpendicular to long ais of theleft ventricle4
View the foreshortened four)cham+er vie*4
2isuali.e the atria, atrial septum and do a colour Doppleron the interatrial septum ssess =2 free *all4 =otate transducer 6 degrees counter cloc/*ise4 =ecord> series of short%axis views4
Transducer groove do*n to*ards patients spine( Liver parenchyma, hepatic vessels inferior venacava4
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#uperior tilt> Drainage of hepatic vein into inferiorvenacava4
=ight rotation> Inferior venacava along its long ais
&olor imaging and Doppler recording of thehepatic vein identifies>
#evere T2 regurgitation,
P'T4
=estrictive filling4 Aurther superior tilt> four cham+er
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#u+costal 2ie*
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#u+)costal 2ie*, short ais
$u!%costal
$hort axis
$u!%costal
$hort axis
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$upra sternal view Etend the patientsB nec/
Place transducer in suprasternal notch, long ais of thetransducer to the left of the trachea4 Transducer groovedirected to the right supraclavicular region4
View;;reat vessels( %scending aorta, aortic arch *iththe origin of the +rachiocephalic trun/, the left commoncarotid artery, the left su+clavian artery from +eforelaterally4
The right pulmonary artery inferior to the aortic arch =otate 6 degrees to vie* short ais of aortic arch *ith
the right pulmonary artery and the left atrium inferior to it4
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!otion9 !) !ode
Produced +y transmission and reception ofultra sound signal along only one line4
Produces a graph of depth and strength of
reflection *ith time4 U# signal should +e aligned perpendiculary
to the structure +eing assessed
&omplimentary mode used to measure si.eand thic/ness of cardiac cham+ers4
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&chocardiography 'asics
$ne)dimensional imaging 0!)mode1
()"'&* "&$+*&"&,T$ ,-
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()"'&* "&$+*&"&,T$ ,-
$$&$$"&,T / $0$TLI(
/+,(TI, Left ventricle
/rom the #- long%axis view> at the level of the
mitral valve tips
%t end diastole measure> septal *all, L2 diastolic
diameter, L2 posterior *all4
%t end)systole measure> L2 systolic diameter4 &alculate fractional shortening 0L2Dd)L2#d9L2Dd1
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Parasternal ais sho*ing
measurement of internal diameter
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Arom !)mode 0if there is no regional *all
a+normality1,ensuring that the !)mode line
is perpendicular to the long ais of the L24
Aractional shortening and e@ection fraction
can +e calculated from these data
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Doppler Echocardiography
Determines the velocity and direction of +lood flo* +ymeasuring the change in fre3uency produced *hensound *aves are reflected from red +lood cells
The Doppler principle states) *hen a sound 0or light1
signal stri/es a moving o+@ect, the fre3uency of thatsignal is altered, and the increase or decrease infre3uency is proportional to the velocity and direction at*hich the o+@ect is moving
Doppler gives hemodynamic information regarding the
heart and +lood vessels &an +e used to detect valvular lea1age2regurgitations
valvular narrowing intracardiac shunts e4 g 2#Ds, %#Ds
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doppler techni3ues
commonly used techni3ues – &ontinuous) Wave 0&W1 Doppler
– Pulsed)Wave Doppler
– &olor)Alo* Doppler
(ontinuous% ave 5(6 -oppler
– #ound *aves are +oth transmitted and receivedcontinuously4 There are t*o crystals in each transducer,one for transmitting and one for receiving4
–
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Pulsed wave doppler
– Utili.es a single crystal to transmit a signal and then
receive after a preset time delay
– #hort +ursts of signal are transmitted from thetransducer at a given pulse repetition fre3uency
0P=A14 – =eflected signals are only recorded from a depth
corresponding to half the product of the time delayand speed of sound in tissues078-6m9s1
– &om+ining this *ith "D imaging a small sample
volume can +e identified on the screen sho*ing theregion *here velocities are +eing measured4
–
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(olor%/low -oppler 5&AD1 !a@or limitations of PW and &W Doppler 0spectral Doppler 1 is that no
spatial information regarding the si.e, shape, and "D direction of flo* is
provided4 In &AD, rapid pulsed)*ave interrogations are performed at multiple sites
for multiple scan lines to create a spatially correct and dynamic display
of moving +lood *ithin the heart and vasculature4
Doppler signals are presented as colors assigned to individual sites
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%pical four)cham+er images *ith color)flo* Doppler during diastole and systole4
=ed flo* indicates movement to*ard the transducer 0diastolic filling1> +lue flo*
indicates movement a*ay from the transducer 0systolic e@ection14 L2, left
ventricle> =%, right atrium> =2, right ventricle
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,ormal Intracardiac -oppler Velocities
=ight ventricle – Tricuspid flo* 64:64G m9sec
– Pulmonary artery 64C:64 m9sec
Left ventricle – !itral flo* 64C:74 m9sec
– %orta 746:74G m9sec
T h l 7 $t
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Transesophageal 7 $tress
&cho
Transesophageal Echo (TEE) Transducer through oesophagus evaluation images of posterior cardiac structures
0e4g4 L%, L% appendage, interatrial septum, aorta
distal to the root1, – Emphysema, Severe obesity, Chest wall deformity
delineation of cardiac structures
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Transesophageal echocardiography
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eporting format
Summarised on a form with $ate, "atient"articulars( ;ame, se, +ndication for theEcho)!
Summary of the =easurements in tabularform Comment on the general shape sie >
function of the 2 and 7 &tria, entricles!
Comment on the valvular function i!e!, =, T,& > "
inal impression given the observations! The report may be accompanied by a C$
or $$ recording of the actual echo!
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eferences
?asper, 'raunward, et al, @arrisonAs"rincriples of +nternal =edicine 04th edition, 6--, =craw @ill "ublishers!
Echo =ade Easy, by Sam ?addoura #illiam anong, 7eview of =edical
"hysiology, 66nd edition, 6--, 2ange!
Boseph ?isslo et al "rinciples of $opplerechocardiography and The $opplerEamination