B Y :

D E E P A K G H I M I R E

M E D I C A L – I N T E R N

S O U T H W E S T E R N U N I V E R S I T Y

S C H O O L O F M E D I C I N E

P R E S E N T E D O C T O B E R , 2 0 1 5

P E R C E P T O R I N C H A R G E : V I C E N T E G . B A L B U E N A , M D

BASIC ECHOCARDIOGRAPHY

ECHOCARDIOGRAPHY

Cardiac Anatomy

Base

Apex

Circulation through the Heart

The Cardiac cycle

4 phases of Diastole

1. Isovolemic relaxation

2. Rapid ventricular filling

3. Slow ventricular filling

4. Atrial contraction

4 phases of Systole

1. Isovolemic contraction

2. Rapid ventricular ejection

3. Slow ventricular ejection

The Cardiac cycle

DIMENSIONS & MEASUREMENT

Internal diameter LV : <5 cm

RV : 2.2 – 4.0 cm

RA: 3.5 – 4.0 4cm

Internal diameter : LA, RA & Ao root : < 4cm

Imaging Modalities

1. 2D- Echocardiography

2. M-mode Echocardiography

Echocardiography

A non-invasive diagnostic technique

Widely used in clinical cardiology.

Involves the use of ultrasound

Used to assess cardiac structure and

hemodynamic function function.

Fig. Echocardiography machine

Indications of 2D Echocardiography

• May be divided into structural imaging and hemodynamic imaging (*ASE)

• Indication for Structural imaging• Pericardial imaging (P. Effusion)

• L/R ventricles & cavities (RVH/LVH or wall motion abnormality or thrombi)

• Image of valves ( Stenosis or prolapse)

• Great vessels (aortic dissections)

• Congenital & Traumatic heart diseases

• Hypertension, suspected IHD, murmurs, Pulmonary disease

• Arrythmias, palpitations, syncope or Neurological disease

Indications of 2D Echocardiography

• May be divided into structural imaging and hemodynamic imaging (*ASE)

• Indication for hemodynamic imaging through Doppler techniques: • Blood flow through heart valves (stenosis/ regurgitation)

• Blood flow through the cardiac chambers (C.O)

• Systolic and diastolic functions

Pocket-sized Echocardiography Machine

Echocardiography

Physics :

Makes use of Ultrasound ( sound >20 Khz frequency)

Usual frequency used : 1– 5 Mhz

Measures two quantities

1. Time Delay between transmission of pulse and reception of echo

2. Intensity of reflected echo

Principle of Image generation

Gray Scale Image

Gray scale Image is generated Based on intensity of reflected echo

Fig: Pericardial effusion

Black Fluid or blood

White Calcifications on cardiac valves/ pericardium

Gray Myocardium

Factors in Echocardiography

Transducers

Use of lens in tranducer

Image Quality

Fig: Image generated by 3 Mhz tranducer

Fig: Image generated by 5 Mhz tranducer

Modes of Display

M-Mode echocardiography

MOTION-MODE (M-MODE) ECHO

Better display of :

Motion and thickness of ventricular walls

Changing size of cardiac chamber

Opening and closure of valves is better

Echocardiography provided information about Structure of heart and great vessels

Doppler imaging provides information about the function, physiology and hemodynamics

Echo vs. Doppler studies

Pulse Continuous

Phased array transducer

The typical frequency range: 1-5 MHz

Has an orientation marker Corresponds with the Image

Transthoracic Acoustic Window

Trans-Thoracic Echo (TTE)

1. Parasternal view

2. Apical view

3. Subcostal view

Trans-Esophageal Echo (TEE)

Assess posterior cardiac

structures

Parasternal Long Axis View (PLAX)

* marker orientated towards the right clavicle (approximately 11 o’clock)

Parasternal Long Axis View (PLAX)

Structure Assessment

RV (right ventricle)

Size and function

LV (left ventricle)

Size and function (septum)

Ao (ascending aorta)

Size

AV (aortic valve)

Motion, opening and calcification

MV (mitral valve)

Motion, opening and calcification

Pericardium Fluids

Assessment :

1. Pericardial space

2. RV

3. Septum

4. LV

5. Anterior MV leaflet

6. Aortic root

7. LA

Parasternal Long Axis View (PLAX)

Parasternal Long Axis View (PLAX)

Fig. Calcification of mitral annulus

Pericardial effusion

Parasternal short-axis view (PSAX)

* PLAXS rotate clockwise 90 degrees ( to long axis of LV)

T

PLAX & PSAX

PSAX

The probe can be tilted to examine the SAX view at different levels:

1. Level of papillary muscles

2. Mitral valve

3. Level of aortic valve

PSAX

Apical Four Chamber View (A4C)

* marker is at around 3 o’clock.

Apical Four Chamber View (A4C)

Assessment :

1. Pericardial space

2. LV

3. Septum

4. RV

5. RA

6. Interartrial septum

7. LA

8.MV annulus

Apical Four Chamber View (A4C)

Apical Five Chamber View

Apical view

Apical Two Chamber View (A2C)

45 to 90 degrees anticlockwise rotation of transducer probe marker from apical view to to 12 o’clock.

Visualizes the true anterior and true inferior walls of the LV

Apical Two Chamber View (A2C)

Subcostal Long Axis View

* Transducer in Right sub xiphiod area & side marker in 3 o’clock position

Subcostal Long Axis View

Assessment :

1. Pericardial space

2. RV

3. Septum

4. MV annulus

5. LV

6. IVC

Trans-Esophageal Echocardiography

Used to assess posterior structures like LA or Aorta

Contrast echocardiography

Before and after contrast

Indications of 2d Echocardiography in evaluation of Heart murmurs

PLAX

MR, AR , VDS

PSAX (multiple level)

AR, TR, PS, PR, VSD

Apical :

4chamber : MR, TR

2 chamber: MR

Long axis: MR, AR, AS, LVOT

5 chamber: LV outflow, AR, AS

Subcostal :

4chamber- RV inflow, TR, ASD

Short axis (Basal) TR, PS, PR

Mid venticular: IVC, HV

Suprasteral:

Aortic arch, Aortic flow

Right Parasternal Lx

Ascending aorta, AS

Two-Dimensional Echocardiography

Cardiac chambers

Chamber size

Left ventricular Hypertrophy

Regional wall motion abnormalities

Valve

Morphology and motion

Pericardium

Effusion

Tamponade

Masses

Great vessels

TransesophagealEchocardiography

Inadequate transthoracicimages

Aortic disease

Infective endocarditis

Source of embolism

Valve prosthesis

Intraoperative

2D Echocardiography

An ideal imaging modality for assessing left ventricular (LV) size and function.

The “gold standard” for imaging valve morphology and motion

The imaging modality of choice for the detection of pericardial effusion

The definitive diagnosis of a suspected aortic dissection usually requires a TEE.

DOPPLER ECHOCARDIOGRAPHY

Uses ultrasound reflecting off moving RBC to

measure the velocity of blood flow across valves,

within cardiac chambers, and through the great

vessels.

Normal and abnormal blood flow patterns can be

assessed noninvasively.

DOPPLER ECHOCARDIOGRAPHY

The different colors indicate the direction of blood flow:

Red toward the transducer

Blue away from the transducer

Green superimposed when there is turbulent flow.

Blue Away Red Towards (BART)

DOPPLER ECHOCARDIOGRAPHY

Valve gradients in stenosis ( Inc. velocity )

Valvular regurgitation (retrograde flow)

Intracardiac pressures (PAH)

Cardiac output (area X velocity)

Diastolic filling

Congenital heart disease (shunts)

VSD

Aortic Regurgitation

Fig: TEE: Dilated ascending aorta Fig. TEE: Aortic Regurgitation

Other use of Echo

Hypovolemia

kissing LV chambers

Collapsing IVC

Temponade

Cardiac Temponade

IVC dilation

Diastolic RV collapse.

Cardiac masses and Tumors

Pleural Effusion

Echocardiography

The quality of an echo is highly operator dependent and proportional to experience and skill.

The value of information derived depends heavily on operation and interpretation

Sources and Assistance

Harrison Principle of Internal medicine, 19th ed

Harrison Principle of Internal medicine, 18th ed

Fiegenbaum's Echocardiography 6th edition

Introduction to Transthoracic echocardiography Stanford University School of Medicine

Radiology staff of SHH, SWU

Good Morning !