Echocardiography by Dr. Milan silwal

1. ECHOCARDIOGRAPHY
Dr. Milan Silwal
Resident,1st year, MD Radiodiagnosis
NAMS, Bir Hospital

2. Presentation outline:
• Conventional Echo
• Color Doppler Echo
• The Transthoracic Echo
• Myocardial Doppler Tissue Imaging and stress echo
• Evaluation of cardiac chambers
• Novel echocardiographic modalities
• The transeosphageal echo

3. • Echocardiography is a highly versatile technique that had become central in
cardiological diagnosis.
• Usually the patient rests in a 45 deg semi-erect position rotated towards
their left side to enhance the cardiac contact to the chest wall.
• Implications of Echo:
Assessment of chamber size, thickness and function
Assessment of cardiac valves
Hemodynamic assessment
Cardiac disease including the valvular and congenital heart diseases
Pericardial disease

4. Conventional Echo
The modalities of echo used clinically are:
I. Image echo
• Two-dimensional echo (2-D echo)
• Motion-mode echo (M-mode echo).
II. Doppler echo
• Continuous wave (CW) Doppler
• Pulsed wave (PW) Doppler.

5. TWO-DIMENSIONAL (2-D) ECHO
• is useful to evaluate the anatomy of the heart and the relationship
between different structures
• Intracardiac masses and extracardiac pericardial abnormalities can be
noted. The motion of the walls of ventricles and cusps of valves is
visualized.
• Thickness of ventricular walls and dimensions of chambers can be
measured and stroke volume, ejection fraction and cardiac output
can be calculated.
• 2-D image is also used to place the ‘cursor line’ for M-mode echo and
to position the ‘sample volume’ for Doppler echo.

6. Fig: Two-dimensional echo (2-D Echo) views:
A. Parasternal long-axis (PLAX) view
B. Apical four-chamber (A4CH) view

7. MOTION-MODE (M-MODE) ECHO
• ultrasound is transmitted and received along only one scan line.
• This line is obtained by applying the cursor to the 2-D image
• M-mode is displayed as a continuous tracing with two axes. The
vertical axis represents distance between the moving structure and
the transducer. The horizontal axis represents time.
• M-mode echo provides greater sensitivity than 2-D echo for studying
the motion of moving cardiac structures.
• Motion and thickness of ventricular walls, changing size of cardiac
chambers and opening and closure of valves is better displayed on M-
mode

8. Fig: Motion-mode echo (M-mode Echo) levels:
A. Mitral valve (MV) level
B. Aortic valve (AV) level

9. CONTINUOUS WAVE (CW) DOPPLER
• CW Doppler transmits and receives ultrasound continuously. It can
measure high velocities without any upper limit and is not hindered by the
phenomenon of aliasing.
• used for rapid scanning of the heart in search of high velocity signals and
abnormal flow patterns.
• display forms the basis for placement of “sample volume” to obtain PW
Doppler spectral tracing.
• used for grading the severity of valvular stenosis and assessing the degree
of valvular regurgitation.
• An intracardiac left-to-right shunt such as a ventricular septal defect can be
quantified.
• signal of the tricuspid valve and pulmonary artery pressure can be
calculated.

10. •
Fig: Continuous wave (CW) Doppler signal of stenotic aortic valve
from multiple views; maximum velocity is 3 m/sec
APX: apical 5 chamber view
RPS: right parasternal view
SSN: suprasternal notch

11. PULSED WAVE (PW) DOPPLER
• PW Doppler transmits ultrasound in pulses and waits to receive the
returning ultrasound after each pulse.
• Because of the time delay in receiving the reflected signal which limits the
sampling rate, it cannot detect high velocities.
• At velocities over 2 m/sec, there occurs a reversal of flow known as the
phenomenon of aliasing.
• However, PW Doppler provides a better spectral tracing than CW Doppler,
which is used for calculations.
• The mitral valve inflow signal is used for the assessment of left ventricular
diastolic dysfunction.
• The aortic valve outflow signal is used for the calculation of stroke volume
and cardiac output.

12. Fig: Pulsed wave (PW) Doppler signal of a stenotic aortic valve
from a single view; maximum velocity is 2 m/sec

13. CLINICAL APPLICATIONS OF ECHO
2-D Echo
• Anatomy of heart and structural relationships.
• Intracardiac masses and pericardial diseases.
• Motion of ventricular walls and valvular leaflets.
• Wall thickness, chamber volume, ejection fraction.
• Calculation of stroke volume and cardiac output.
• Architecture of valve leaflets and size of orifice.
• Positioning for M-mode image and Doppler echo.

14. M-Mode Echo
• Cavity size, wall thickness and muscle mass.
• Excursion of ventricular walls and valve cusps.
• Timing of cardiac events with synchronous ECG.
• Timing of flow pattern with color flow mapping.

15. CW Doppler
• Grading the severity of valvular stenosis.
• Assessing degree of valvular regurgitation.
• Quantifying the pulmonary artery pressure.
• Scanning the heart for high velocity signal.

16. PW Doppler
• Assessment of left ventricular diastolic function.
• Calculation of stroke volume and cardiac output.
• Estimation of orifice area of stenotic aortic valve.
• Localization of flow pattern seen on CF mapping.
• Localization of signal picked up on CW Doppler.
• Application of spectral tracing for calculations

17. Color Doppler Echo
• is an automated version of the pulsed-wave Doppler. It is also known as
real-time Doppler imaging.
• The colors assigned to blood flow towards the transducer are shades of red
while colors assigned to flow away from the transducer are hues of blue.
• As the velocity of blood flow increases, the shade or hue assigned to the
flow gets progressively brighter. Therefore,
low velocities appear dull and dark
high velocities appear bright and light.
• When blood flow at high velocity becomes turbulent, it superimposes color
variance into the color flow map. This is seen as a mosaic pattern with
shades of aquamarine, green and yellow.

18. • The gray-scale tissue-gain setting must be just enough to provide
structural reference.
Setting the tissue-gain too low blurs the anatomical image.
Setting the tissue-gain too high induces gray-scale artefact or
“background noise” and distorts the color display
• The velocity-filter and color-gain settings must be optimal.
Setting the filter high and gain low may miss color flow maps of
low velocities.
Setting the filter low and gain high may introduce color artefacts
from normal structures and obscure genuine color flow maps.

19. Advantages:
• rapidity with which normal and abnormal flow patterns can be
visualized and interpreted.
• spatial orientation of color flow mapping is easier to comprehend.
• improves the accuracy of sampling with PW and CW Doppler by
helping to align the Doppler beam with the color jet. This facilitates
localization of valve regurgitation and intracardiac shunts.
• phenomenon of aliasing, a disadvantage in PW Doppler, is
advantageous during color flow mapping. Introduction of color
variance in the flow map is easily recognized as a mosaic pattern.

20. Limitations:
• Color Doppler is sensitive to pulsed repetition frequency (PRF) of the
transducer and the depth of the cardiac structure being interrogated.
• Color Doppler may inadvertently miss low velocities if the flow signal
is weak.
• Color Doppler may spuriously pick up artefacts from heart muscle and
valve tissue if velocity filter setting is low and color gain setting is
high.
• Complex cardiac lesions may produce a multitude of blood flows in a
small area resulting confusional riot of color, hindering rather than
helping an accurate diagnosis.

21. APPLICATIONS OF COLOR DOPPLER
• Stenotic Lesions
localize and quantitate stenotic lesions of the cardiac valves
• Regurgitant Lesions
Color Doppler can diagnose and estimate the severity of
regurgitant lesions of the valves
• Intracardiac Shunts
ASD, VSD, PDA

22. The Echo Windows
• Transthoracic Echo
• Transesophageal Echo

23. Two-Dimensional Trans-thoracic Examination
• directed through a number of selected
planes to record a set of standardized
views of the cardiac structures
• Views designated by
• the position of the transducer,
• the orientation of the viewing plane relative
to the primary axis of the heart,
• the structures included in the image

24. Imaging planes:
A. Left parasternal
B. Apical
C. Subcostal
D. Suprasternal
E. Right parasternal

25. A. Left parasternal:
I. Long axis left ventricle
II. Short axis aortic valve level
III. Short axis mitral valve level
IV. Short axis papillary muscle level
V. Short axis apical level

26. Left Parasternal Imaging Planes
• Transducer:along the left parasternal intercostal spaces (2nd -4th).
• Marker dot direction: points towards right shoulder.
• long- and short-axis images of the heart are obtained.
• long-axis view - mitral leaflets and chordal apparatus, right
ventricular outflow tract, aortic valve, left atrium, long axis of the
left ventricle, and aorta.
• Rightward angulations allow more complete imaging of the right
ventricle. The right ventricular inflow view allows assessment of
the right atrium, the proximal portion of the inferior vena cava,
and the entry of the coronary sinus, the tricuspid valve, and the
base of the right ventricle.

27. Fig. Parasternal long axis view of left
ventricle; in this diastolic image, the
mitral valve leaflets are open and the
aortic valve leaflets are closed. The
descending aorta can be seen in cross
section as it passes beneath the left
atrium
Fig. parasternal view of the long axis
of the right heart. The tricuspid valve
leaflets (arrowheads) are seen closing
in systole.

28. Fig. parasternal short-axis view at the base of
the heart. The aortic root with its three aortic
sinuses is shown in the center with the left
atrium directly posterior to it. A prominent left
atrial appendage is present (long arrow), and
the left upper pulmonary vein can be seen
entering the left atrium. The right ventricular
outflow tract lies anterior to the aorta, with the
posterior cusp of the pulmonic valve depicted
by the short arrow
• Parasternal short-axis images of the
heart – transducer rotated 90 degrees
from the long-axis plane.
• Short Axis Levels
1. aortic valve level
2. mitral valve level
3. papillary muscle
4 left ventricle .
• The most cranial view – aortic valve
level
visualization of the aortic valve, atria,
right ventricular outflow tract, and
proximal pulmonary arteries.
• The three normal coronary cusps of the
aortic valve can be viewed with possible
imaging of the proximal right coronary
artery arising from the right coronary
cusp at the 10 o’clock position, and the
left main coronary artery originating
from the left coronary cusp at the 3
o’clock position.

29. Fig. Parasternal short-axis view of the left
ventricle at the level of the mitral valve. In
diastole, the mitral valve leaflets are open
in a “fish mouth” pattern. The left ventricle
appears circular and the right ventricle is
crescentic in shape
• At the basal level, the fish-
mouthed appearance of the
mitral valve is apparent.
• At the mid-ventricular level,
the anterolateral and
posteromedial papillary
muscles are seen.
• The most caudal angulation
allows visualization of the left
ventricular apex.

30. Fig. Parasternal short-axis view of the left
ventricle at the level of the papillary muscles.
Both papillary muscles can be seen projecting
into the lumen of the left ventricle.
Fig. Parasternal short-axis view of the left
ventricle at the level of the apex.

31. B. Apical:
I. Four chamber
II.Five chamber
III.Apical long axis of left ventricle
IV.Two chamber

32. Apical Imaging Planes
• Transducer placed at the
cardiac apex and orienting
the imaging sector toward
the base of the heart;
• visualization of all chambers
of the heart and the tricuspid
and mitral valves.
• With the transducer oriented
in a mediolateral plane, an
apical four-chamber view of
the heart is obtained.
Fig. Apical four-chamber view of the heart.
LA, left atrium; LV, left ventricle; RA, right atrium; RV,
right ventricle.

33. •Superficial angulation of the
scanning plane from the apical
four-chamber view brings the left
ventricular outflow tract and
aortic valve into view, producing
the five-chamber view.
Fig. Apical five-chamber view of
the heart. Includes left ventricular
outflow tract and aortic valve.

34. Fig. Apical long-axis view of the heart. To
obtain this view, the transducer is rotated
so that the index marker is pointed toward
the suprasternal notch. AV, aortic valve; LA,
left atrium; LV, left ventricle.
• As the transducer is rotated 45
degrees clockwise to this plane,
the apical long-axis view of the
heart is obtained.

35. • Further clockwise rotation of the
transducer to a full 90 degrees
produces the apical two-chamber
view
The apical two-chamber view -
direct visualization of the true
inferior and anterior wall of the
ventricle.
.
Fig. Apical two-chamber view of the heart.
To obtain this view, the transducer is rotated
45 degree clockwise from
the long-axis view. This image plane lies
between long-axis view and
four-chamber view.
anterior (Ant) and inferior (Inf)
walls ; LA, left atrium; LV, left ventricle.

36. C. subcostal
I. Four chamber

37. Subcostal Imaging Planes
• Access to the heart through the solid tissue of the liver, which readily
transmits sound waves - better visualization of the atrial and ventricular
septae because the sound beam strikes these structures in a perpendicular
direction.
• A series of long- and short-axis images are usually obtained from this
window. The inferior vena cava and hepatic veins, the liver, and the
abdominal aorta can also be evaluated subcostally.
• it may be the only viewpoint to image the heart in the patient with chest
wall injury, hyperinflated lungs, or pneumothorax.
• In infants and small children, the subcostal window provides excellent
images of all cardiac structures.

38. D. Suprasternal:
aortic arch

39. Suprasternal Imaging Planes
• by placing the transducer in the
suprasternal notch.
• Both longitudinal and
transverse planes of the great
vessels can be imaged.
• The longitudinal plane orients
through the long axis of the
aorta and includes the origins of
the innominate, left common
carotid, and left subclavian
arteries.
Fig. suprasternal long-axis view of the aortic arch. The proximal
portions of the brachiocephalic vessels are demonstrated arising
from the aortic arch: (1) right brachiocephalic artery, (2) left
common carotid artery, and (3) left subclavian artery. The right
pulmonary artery (RPA) can be seen in cross section as it passes
beneath the ascending aorta (Ao). DAo, descending aorta; LA,
left atrium.

40. • The transverse plane includes a cross
section through the ascending aorta,
with the right pulmonary artery
crossing behind. Portions of the
innominate vein and superior vena
cava are visible anterior to the aorta.
The left atrium and pulmonary veins
are posterior to the right pulmonary
artery. Fig. Suprasternal short-axis view of the aortic arch.
The right pulmonary artery (RPA) crosses beneath the
aorta (Ao) and the pulmonary veins enter the left
atrium with a “crablike” appearance. LA, left atrium;
LIPV, left inferior pulmonary vein; LSPV, left superior
pulmonary vein; RIPV, right inferior pulmonary vein;
RSPV, right superior pulmonary vein

41. E. Right Parasternal View
• particularly helpful with medially positioned hearts, right ventricular
enlargement, and rightward orientation of the ascending aorta.
• By allowing direct visualization of the right atrium, both venae cavae,
and the interatrial septum, this view is also of particular value in the
assessment of interatrial shunt flow, and in the detection of
anomalous pulmonary venous drainage.

42. The Normal Doppler Examination
• Frequency shift of ultrasound waves reflected from moving red blood
cells can be used to determine the velocity and direction of blood
flow.
• Done with either pulsed Doppler or continuous wave Doppler.
• Pulsed Doppler (uses PRF) - analysis of the velocity and direction of
blood flow at a specific site.
• Continuous wave Doppler - resolution and analysis of high-velocity
flow along the entire length of the Doppler beam.

43. Fig. Continuous wave Doppler spectral tracing of
flow across the mitral valve from the apical
window.. In systole, mitral regurgitant flow is
shown below the baseline as it passes away from
the apex and into the left atrium. This patient
with rheumatic mitral stenosis has high velocity
mitral inflow (1.8 m/sec) and mitral regurgitation
(5 m/sec).
• The data can be displayed
graphically.
• The x-axis represents time and
the y-axis represents velocity.
• By convention, flow toward
the transducer is represented
as a deflection above, and
flow away from the transducer
appears as a deflection below
the baseline.

44. Fig. parasternal long-axis view of the mitral
valve in systole. A large stream of mitral
regurgitation (MR) (arrowhead) is seen
emerging from the leaflet coaptation point and
spreading into the left atrium (LA). The jet is
blue (indicating flow away from the
transducer) with mosaic of color to reflect
turbulent flow. LV, left ventricle.
• Parasternal Long-Axis View
• In this view, mitral regurgitation is
seen as a discrete blue jet in the left
atrium during systole. Small jets can
be seen with normal valves.
• Aortic regurgitation is seen as blue or
red jet emanating from a closed
aortic valve. The jet is located in the
left ventricular outflow tract and
occurs in diastole. The presence of
this jet represents an abnormal
aortic valve.

45. • Right Ventricular Inflow View
• IVC inflow is seen as a red jet seen at the inferior margin of the right
atrium. It has both systole and diastole phases and flow velocity is
normally less than 1.0 m/sec by pulsed Doppler.
• Tricuspid inflow is seen as red jet crossing the tricuspid valve. It
occurs in diastole with velocities less than 0.6 m/sec.
• TR is a blue jet in the right atrium which occurs in systole. Small jets
are normal. The peak velocity of regurgitant flow can be quantified by
continuous wave Doppler.

46. • Parasternal Short Axis
• Inferior vena cava inflow is a continuous low-velocity red jet that
enters through the right atrial floor adjacent to the interatrial septum.
• Vigorous caval flow such as seen in children may be confused with left
to right interatrial shunt flow.
• Pulmonary outflow is a systolic blue jet in the pulmonary artery. The
normal velocity across the pulmonary outflow tract is 0.6 to 0.9
m/sec in adults and 0.7-1.2 m/sec in children.

47. • Apical Views
• Transmitral and tricuspid flow are best evaluated in the four chamber view as a
result of the parallel position of the doppler beam to the direction of blood flow.
• Likewise, transaortic flow can be assessed in the apical long axis or five-chamber
view.

48. • The flows detected in this view are:
• Mitral inflow occurs in diastole and can be quantified by pulsed
Doppler with the sample volume placed at the mitral leaflet tips in
the ventricular cavity.
• The initial positive deflection (E wave) represents early passive
ventricular filling and the subsequent deflection (A wave) reflects the
late phase of ventricular filling that is as a result of atrial contraction.
• The normal E wave velocity is less than 1.2 m/sec and A wave
velocity is less than 0.8 m/sec.

49. Fig. Pulsed Doppler spectral profile of mitral inflow obtained from
an apical window. Flow toward the transducer is shown above the
baseline in diastole during left ventricular filling. The typical mitral
biphasic-filling pattern is seen, with a prominent early filling wave
(E wave) and smaller late diastolic filling wave (A wave).

50. • Aortic and left ventricular outflow is seen as blue flow detected in
systole. The Doppler profile appears as a negative single uniform
systolic profile.
• Pulmonary vein inflow from the right upper pulmonary vein is seen as
a red jet entering the left atrium in proximity of the interatrial
septum. It can be quantified by pulsed Doppler with sample volume
placed 1 to 2 cm into the pulmonary vein. There is biphasic flow in
systole and diastole.

51. Fig. Pulsed Doppler spectral profile of aortic outflow obtained from
an apical window. Flow velocities are plotted below the baseline to
indicate that the direction of flow is away from the apically
positioned transducer. The typical aortic flow profile is a systolic
flow with rapid upstroke to a peak velocity in mid-systole and rapid
decline in velocity during late systole.

52. • Other Views
Subcostal views are useful for assessing flow within the inferior vena
cava, hepatic veins, and abdominal aorta. The suprasternal window is
used for recording flow in the ascending and descending aorta and in
the superior vena cava.

53. Myocardial Doppler Tissue Imaging
• myocardium (low velocity) as the target of ultrasound reflection
rather than blood cells (high velocity).
• Similar Doppler principles can be applied with color saturation of the
tissue to indicate direction and velocity of the myocardium.
• sample volume (similar to pulsed Doppler) placed within the
myocardium or valvular annulus to obtain a quantitative spectral
profile of myocardial motion.
• Doppler derived tissue velocity, strain and strain rate have been
demonstrated to improve evaluation of myocardial mechanics when
compared to previous measures such as wall thickening or motion

54. Fig. Tissue Doppler imaging shows
myocardial velocity in a target sample
region. In this case the sample volume is
placed at the septal mitral annulus. The
systolic motion of the annulus (s′) and
the diastolic motion (e′ and a′) are
shown.
Fig. Tissue velocity derived radial strain of
the left ventricle shown from the
midventricular short axis. The two areas of
interest are shown by ovals superimposed
on the myocardium. The peak strain value
for normal myocardium (anteroseptum,
yellow curve) has a higher positive strain
(myocardial lengthening) than
dysfunctional myocardium (inferior wall,
green curve) during systole.

55. Evaluation of Cardiac Chambers
Aortic root—end diastole 24-39 mm
Left atrium—end systole 25-38 mm
Left ventricle—end diastole 37-53 mm
Interventricular septal thickness—end diastole 7-11 mm
Left ventricular posterior wall thickness—end diastole 7-11 mm
*Obtained from para-sternal long-axis view.
Normal Linear Dimensions
• By convention, most laboratories report the size of the left
atrium, aortic root, and left ventricle from the measurement of
the linear dimensions of each structure in the para-sternal
long-axis view of the heart.
• All linear dimensions - bear a direct linear relation to body
height.

56. Left Ventricular Volume
• The ellipsoid formula
• requires measuring the length of the ventricle and its diameter at the base.
This volume estimation is valid in normal (symmetric) left ventricles, but it is
less reliable when there is a distortion of ventricular shape (e.g., following
myocardial infarction).
• Simpson’s rule
• requires measuring the length of the ventricle from apical views and then
determining the volume of a predefined number of disk-like cross-sectional
segments from base to apex.

57. • Three-dimensional volume measurement
makes no geometric assumptions and
thus can determine the volume of both
normal and distorted ventricles.
Fig. A three-dimensional left ventricular volume
assessment allows all regions of the ventricular
myocardium to be incorporated into the volume
assessment. Each region is depicted by the
different color code representing the 17-
segment model. The image is from a patient
with dilated cardiomyopathy and thus the
ventricular shape is more globular in structure.

58. Left Ventricular Systolic Function from Two-dimensional Images
• Real-time echocardiographic assessment of endocardial motion and
the degree of wall thickening during systole allows excellent
qualitative assessment of global and regional ventricular function.
• Using this method, systolic function can be described as either normal
or depressed, and regional function is either normal, hyperkinetic,
hypokinetic, akinetic, or dyskinetic.

59. Left Ventricular Systolic Function from Doppler Echocardiography
• Doppler echocardiography makes it possible to estimate stroke
volume and cardiac output by measuring volumetric flow through the
heart.
• Stroke volume is calculated by measuring the cross-sectional area of a
vessel or valve (e.g. aortic valve diameter and flow velocities ) and
then integrating the flow velocities across that specific region in the
vessel or valve throughout the period of flow.
• The product of stroke volume and heart rate then gives an estimate of
cardiac output.

60. Left Atrium
• anteroposterior dimension measured at end systole in the parasternal
long-axis view from a line drawn through the plane of the aortic valve.
• Atrial enlargement may occur as a consequence of
increase in atrial pressure (resulting from mitral stenosis or elevated left
ventricular end-diastolic pressure),
increase in volume (as in mitral regurgitation),
consequence of primary atrial dysfunction (as in atrial fibrillation).
• The left atrial appendage is a “dog ear”-shaped extension of the
atrium situated along the lateral aspect of the chamber near the
mitral annulus. - trabeculated structure can be confused with
thrombus, which may form within the appendage

61. Fig. A two-dimensional transesophageal echocardiogram showing
the left ventricle (LV), left atrium (LA), left atrial appendage (LAA),
and large thrombus (arrowheads).

62. Right Ventricle
• Morphologically, divided into
an inflow portion: heavily trabeculated,
an outflow portion: infundibulum.
• The inflow portion extends from the tricuspid valve to the apex.
• The lateral or free wall of the right ventricle normally has a radius of
curvature approximately equal to the left ventricular free wall.
• complex shape of the right ventricle, so is less amenable to geometric
modeling than the left ventricle.Thus, newer three-dimensional
echocardiographic techniques are more reliable in assessing right
ventricular volume.

63. • Right ventricular enlargement may be due to
volume loading, right ventricular infarction, or as part of a generalized
cardiomyopathic process.
In each instance, as dilatation progresses, the anteroposterior
dimension of the ventricle increases and interventricular septal motion
becomes increasingly abnormal.
• Pressure loading results in progressive hypertrophy.
• free wall thickness of greater than 5 mm is a quantitative criterion for right
ventricular hypertrophy.
• Marked pressure overloading typically produces systolic flattening of the
interventricular septum.

64. Fig. Apical four-chamber view of a patient with severe primary pulmonary
hypertension. The right ventricle (RV) is enlarged. There is hypertrophy of the
free wall (RVH). The right atrium (RA) is enlarged and high right atrial pressures
cause displacement of the interatrial septum (IAS) to the left. The left atrium
(LA) and left ventricle (LV) are under filled as a result of the reduced output
from the right heart and are thus small.

65. Right Atrium
• Assessed qualitatively by comparing it to the left atrium in the apical four-
chamber view and quantitatively by measuring the maximal mediolateral
and supero-inferior dimensions in this view.
• Normal structures within the right atrium include
• Eustachian valve (or valve of IVC), which crosses from the inferior vena cava to the
region of the foramen ovale, and
• Crista terminalis; apical four chamber view - a ridge of tissue that separates the
smooth-walled portion of the right atrium from its trabeculated anterior portion,
often noted as a small mass of echoes located adjacent to the superior border of the
right atrium.
• right atrial appendage: a broad-based triangular structure anterior to the atrial
chamber near the ascending aorta; most visible in the parasternal views of the right
atrium and readily visualized by TEE.

66. Novel Echocardiographic Tools:
1. Contrast Echocardiography
• Contrast echocardiography uses intravenous agents that result in
increased echogenicity of blood or myocardium with ultrasound
imaging.
• Contrast agents form small microbubbles, which at low ultrasound
power, output disperse ultrasound at the gas and liquid interface, thus
increasing the signal detected by the transducer.
• Contrast echocardiography improves analysis of regional wall
abnormalities. Real-time myocardial contrast echocardiography is
being investigated as a tool for quantitative analysis of myocardial
perfusion.

67. Fig. Apical four-chamber view recorded
of a patient with left ventricular apical
pseudoaneurysm (PSA) following left
ventricular contrast agent injection
showing complete cavity opacification
and delineation of all left ventricular
walls. IVS, interventricular septum; LV,
left ventricle; RV, right ventricle.
Fig. Apical four-chamber view recorded after the
injection of contrast into an upper limb vein. Contrast
is seen to fill the right atrium (RA) and right ventricle
(RV) before entering the left atrium (LA) and left
ventricle (LV). The image is acquired after a Valsalva
maneuver that transiently increases the right atrial
pressure. This is reflected in the leftward displacement
of the interatrial septum (IAS) resulting in increased
right to left flow through the patent foramen ovale.

68. 2. Three-Dimensional Echocardiography
• Volumetric imaging using a complex
multi-array transducer
• Three-dimensional pyramidal volume
data used to obtain images of the cardiac
structures in three spatial dimensions.
• Post-acquisition processing allows
different views of the interior structures
of the heart to be displayed.
• The structure studied can be manipulated
so that it is viewed from multiple angles
such as the surgical enface view of the
mitral valve from the left atrium.
Fig. 3-D enface view of the mitral valve from
the left atrial perspective -prolapse of the
middle scallop of the anterior mitral leaflet
(pAMVL).

69. • Real-time 3-D transesophageal
echocardiography (TEE) - to
assist with device implantation
in the catheter laboratory.
• current limitations: image
quality, ultrasound artifact, and
temporal resolution.
Fig. 3-D study recorded during an ASD closure procedure.
The image is recorded from the left atrial aspect showing
the catheter traversing the atrial septal defect (ASD). The
Atrial Septal Closure device (AMP) is seen at the tip of the
catheter (CATH) as it is being positioned along the
interatrial septum.

70. Transesophageal Echo
• visualize the heart and great vessels in
patients with suboptimal transthoracic
imaging windows.
• This may occur as a result of body
habitus, lung disease, or operative room
or intensive care environment where
access to the chest wall and optimal
positioning is prohibitive.
• uses a specially designed ultrasound
probe incorporated within a standard
gastroscope - semi-invasive procedure
requiring blind esophageal intubation.

71. • High-frequency transducers (5.0 to 7.5 MHz) are
routinely used because of close proximity of the heart to
the transducer - better definition of small structures than
the lower frequencies used transthoracically (2.5 to 3.5
MHz).
• particularly valuable for the detection of: atrial thrombi,
small vegetations, diseases of the aorta, atrial septal
defects, patent foramen ovale, and the assessment of
prosthetic valve function.

72. • In operating or catheter suites to monitor and assess the repair of
cardiac structures.
• Current instrumentation allows imaging of multiple planes through
the heart with multiplane transesophageal probes in which the
ultrasound plane is electronically steered through an arc of 180
degrees.
• The anteroposterior orientation of images from the esophagus is the
reverse of images from the transthoracic window because the
ultrasound beam first encounters the more posterior structures
closest to the esophagus.

73. Fig. Diagrammatic representation of the standard imaging planes obtained with multiplane
transesophageal echocardiography. Views from the upper esophageal, midesophageal, and
transgastric probe orientations are demonstrated. The icon adjacent to each view indicates the
approximate multiplane angle. AV, aortic valve; LAX, long axis; ME, midesophageal; RV, right
ventricle; SAX, short axis; TG, transgastric; UE, upper esophageal.

74. Thank You!

75. References
• Cardiac Imaging: The Requisites by Stephen W Miller et al 3rd edition
• Echo Made Easy by Atul Luthara 3rd edition
• https://www.echopedia.org