echo kibudde

8/16/2019 Echo Kibudde

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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

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