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IN

ECHOCARDIOGRAPHYJanette LaFroscia

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EchocardiographyINTRODUCTION

• Echocardiograms are one of the most commonly performed cardiac studies

• Provide comprehensive information about cardiac structure and function

• Aid in establishing diagnosis and guiding treatment

• Can be ordered by all physicians, not just cardiologists

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Transthoracic Echocardiography- TTE

• Hand-held ultrasound probe positioned in specific areas (windows) to visualize heart

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Transesophageal Echocardiography-TEE

• Performed by inserting a small (~1/2 inch) ultrasound probe into the esophagus

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Intracardiac Echocardiography-ICE

• Thin catheter (8 Fr) with ultrasound transducer at tip, inserted directly into the RA through femoral venous access

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Orientation

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BASICSULTRASOUND PHYSICS

• TEE and ICE: Higher frequency sound waves generate high resolution images• Waves do not travel far, but allows for

imaging of finer details• TEE uses frequency of 7 MHz, ICE uses

5-10 MHz

• TTE: Lower frequency sound waves generate lower resolution images• Allows for deeper penetration of waves

through more tissue, adequate for most situations

• TTE uses frequency of 3 MHz

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Comparison

TTE

TEE

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Indications for Echo

• Assessment of LV function• Most common reason an echo is ordered• Most useful measurement is Ejection Fraction

• Difference in LV volume at end-systole and end-diastole

• Normal range is 55%-65%

• Wall motion abnomalities (WMA) can be described

• Hypokinesis- LV contraction is diminished• Akinesis- no contraction• Dyskinesis- uncoordinated contraction

http://www.youtube.com/watch?v=amCLvflTUCINormal LV function PLAXhttp://www.youtube.com/watch?v=V0kepFF4AEsNormal LV function APICAL4

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Hozumi T et al. Heart 2003;89:1163-1168

©2003 by BMJ Publishing Group Ltd and British Cardiovascular Society

WMA

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Indications for Echo

• Murmurs

• Abnormal heart sounds caused by abnormal blood flow through the heart

• Valvular heart disease• Increased flow across normal valve• Shunts due to congenital or acquired

defects• Tumors

http://www.medicanalife.com/watch_video.php?v=f88e591176322f2Myxoma

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Indications for Echo• Aortic Valve Disease

• Aortic Stenosis• Assess valve opening and mobility of

cusps• Note presence of calcium or

thickening• Measure velocity of blood flow across

valve • Calculate valve area

• Aortic Regurgitation• Assessed using Doppler

http://www.echojournal.org/video/16/Aortic-ValveNormal AO valvehttp://www.youtube.com/watch?v=MJoEyHxoi5YAortic stenosis, 2D and 3D

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Aortic Stenosis

CONTINUOUS WAVE DOPPLER

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Indications for Echo

• Mitral Valve Disease

• Mitral Regurgitation• Assess closure of valve leaflets• Assess with Doppler

• Mitral Stenosis• Caused by rheumatic heart disease• Check for abnormal thickening and

opening of leaflets

http://www.youtube.com/watch?v=yN8z01DAgVYMitral valve PSAXhttp://www.youtube.com/watch?v=amCLvflTUCIMitral valve PLAX

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Indications for Echo

• Atrial Fibrillation

• Can be related to valvular disease, CAD, diastolic dysfunction, or cardiomyopathy

• Echos can assess any underlying problems and guide treatment

• Best to control rate before study• Patients with major structural

abnormalities, significant LV systolic dysfunction, or LA diameter >4.5 cm are less likely to maintain SR after CV

http://www.youtube.com/watch?v=XgJoO_f7xZgAF

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Indications for Echo

• Stroke/TIA

• Up to 20% of CVA’s may be caused by cardiac emboli

• TTE rarely shows a direct source of emboli (such as thrombus, vegetations, or tumors)

• Shows abnormalities which predispose a patient to embolization (such as MV disease, PFO, or LV aneurysm)

• TEE is an effective screening tool to detect LAA thrombus before CV of AF and AF ablation procedures

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TEE Screening for LAA Thrombus

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TEE Screening for LAA Thrombus

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TEE Screening for LAA Thrombus

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Indications for Echo

• Infective Endocarditis• Bacterial infection of heart valves

• Established bacteria is called a vegetation• Damaged and abnormal valves are at

higher risk• Acute (staph) versus subacute (strep)• Symptoms: fever, murmur, emboli, stroke• IV drug abuse can increase risk of bacterial

endocarditis• Can also be used in setting of suspected

device system infectionhttp://www.youtube.com/watch?v=RN9jzqg2z98 Mitral Vegetation

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Indications for Echo

• Assessment of Artificial Valves

• Can be used for tissue and mechanical valves

• Check for regurgitation and leaking of blood around valve annulus

• Check velocity of blood flow through the valve

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Indications for Echo

MISCELLANEOUS

• Assessment of ASD/VSD/PFO

• Pericarditis/Pericardial Effusion/Cardiac Tampanade

http://www.youtube.com/watch?v=KoMBYodwXpY&feature=results_main&playnext=1&list=PL7E09221BF7CC64C9

• Suspected Aortic Dissection

http://www.youtube.com/watch?v=p2WPALg2W7Q VSD

http://www.youtube.com/watch?v=nD8DrZCPFBI&feature=related Dissection in ascending aorta

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Indications for Echo

MISCELLANEOUS

• Visualization of interatrial septum for transseptal procedures- ICE

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Conclusion

SUMMARY

• Echocardiography is a valuable tool in the diagnosis and

management of cardiac patients

• Consider the indication and chose echocardiography method accordingly

• An echo study needs to be performed by skilled technologists and physicians for accurate results

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Echocardiograms

VIDEOShttp://www.youtube.com/watch?v=B3un6pFV8So (normal echo)

http://www.youtube.com/watch?v=N61stug0oBM&feature=related (AS, LVH, Rt side dilatation, PPM, MR, AI)

http://www.youtube.com/watch?v=mlsbfqZljSE&feature=related (LV thrombus)

http://www.youtube.com/watch?v=izDZnG4T8bc (bubble study)

http://folk.ntnu.no/stoylen/strainrate/Ultrasound/ Ultrasound Review

ARTICLEShttp://www.eplabdigest.com/article/4148 ICE Overview