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History of echocardiography

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History of echocardiography

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History of echocardiography

  1. 1. The History of Echocardiography Raghu kishore Galla
  2. 2. Early Developments in Echocardiography The importance of echo reflection, the concept behind echocardiography, was first demonstrated by Lazzaro Spallanzani (1729– 1799), when he showed that reflected echoes of inaudible sound enabled bats to navigate.
  3. 3. With the discovery of piezoelectricity by the Jaques Curie and Pierre Curie in 1880 came the ability to create ultrasonic waves from quartz crystals
  4. 4. The first suggestions of locating submerged objects by echo-reflection probably came after the Titanic disaster in 1912 Lewis Richardson's suggestion, in 1912, that an echo-ranging technique could be used to detect underwater objects was followed by the development of the SONAR (Sound Navigation and Ranging). system by Langevin in 1915,in time to be used for detecting enemy submarines during World War I
  5. 5. Paul Longevin
  6. 6. • A variety of subsequent discoveries were made that culminated in the first patent for ultrasonic, nondestructive flaw detection, issued to Sokolov in 1937. • Firestone received a patent in 1942 for a somewhat similar device. • Developments in this field accelerated quickly during World War II, when this application was used for naval sonar.
  7. 7. • After the end of World War II, numerous investigators sought peaceful uses for wartime technology. • Sonar or diagnostic ultrasound was one of many such technologies. • The early devices often used crude, two-dimensional scanning techniques. • There were also A-mode examinations, whereby one merely looked at the location and amplitude of the returning ultrasonic signal. Virtually every organ of the body was scrutinized. • Most of the early work was done by physical scientists. Very little was reported in the medical literature, and these investigations had minimal if any clinical impact for many years.
  8. 8. • Wild was probably the first of the early investigators to examine the heart ultrasonically. • This work was done primarily with autopsy specimens. • It is interesting that one of his coworkers was Reid, who went on to make many important contributions to the field. • Neither Wild nor Reid was a physician.
  9. 9. • The Austrian K. T. Dussik was the first to apply ultrasound for medical diagnosis in 1941 • He tried to outline the ventricles of the brain using echo- transmission, a principle similar to X- ray imaging. • Dussik can be regarded the ‘father of diagnostic ultrasound’
  10. 10. Clinical Cardiac Ultrasound • The first use of echocardiography as we know it today is usually credited to Paul Edler and Hellmuth Hertz.
  11. 11. • Edler was a cardiologist practicing at Lund University in Sweden and was in charge of the cardiology department of the medical clinic. • Hertz, who was a physicist, had a long-standing interest in using ultrasound for the measurement of distances. • Hertz came from a very famous family. Both his father and his uncle were internationally known physicists. One won the Nobel prize in physics and the other was the man whose name was appropriated to describe wave frequencies.
  12. 12. • Hertz was familiar with the work of Firestone, and he collaborated with Edler to see whether this technique would be useful in examining the heart. • Hertz located a commercial ultrasonic reflectoscope used for nondestructive testing. • The first person to be examined was himself. He identified a signal that moved with cardiac action. • It was with this instrument that the field of echocardiography, using the time-motion or M-mode approach, began
  13. 13. • One of Edler’s principal medical concerns in those days was mitral stenosis. • He concentrated on this application for the ultrasonic examination that he now called “ultrasound cardiography.” • He was able to record several signals from the heart, but identification of these echoes was difficult. • He described a signal that we now know originates from the anterior leaflet of the mitral valve. However, initially he thought that this echo was coming from the back wall of the left atrium.
  14. 14. • The manner in which he discovered the true identity of this echo is interesting. • Edler performed ultrasonic examinations on patients who were dying. • He marked the location and direction of the ultrasonic beam. When the patient died, he stuck an ice pick into the chest in the direction of the ultrasonic beam. • At autopsy, he discovered that the beam transected the anterior leaflet of the mitral valve and not necessarily the back wall of the left atrium.
  15. 15. One of the earliest M-mode echocardiograms of the mitral valve, recorded by I. Edler and C. H. Hertz in December 1953. The sensitivity of the transducers used at that time allowed the recording of echoes from diseased valves only, and not from normal valves
  16. 16. • Edler reported several structures that he identified on the ultrasound cardiogram. • He made a film that was shown at the European Congress of Cardiology in Rome in 1960. • In this film, he described the mitral valve with mitral stenosis and several other normal structures, such as the cardiac valves and the aorta. • He noted the back wall of the left ventricle. • There was also a description of a patient with a large anterior pericardial effusion.
  17. 17. • He wrote a fairly extensive review article that appeared in Acta Medica Scandinavia in 1961. • Despite these many ultrasonic findings, the main application that he thought was practical was the detection of mitral stenosis. • He relied entirely on the M-mode diastolic E-to-F slope for both the qualitative and quantitative diagnosis. • He also used this measurement to help differentiate mitral stenosis from mitral regurgitation
  18. 18. • It was not until Harvey Feigenbaum was suddenly possessed by the notion of cardiac ultrasound that echocardiography really took hold. • While at an American Heart Association meeting in 1963, he placed the transducer of a machine that was advertised to measure cardiac volumes on his chest. • What he saw was a similar echo seen by Hertz 10 years earlier, and that observation literally became a “life-changing event.” • Thus began his work on echographic detection of pericardial effusions that culminated in a publication in1965. • By 1968, Feigenbaum had begun his echocardiography courses
  19. 19. Dr. Feigenbaum with an early echocardiography machine at the IU School of Medicine. | Photo courtesty the Krannert Institute of Cardiology
  20. 20. History of the term ECHOCARDIGRAPHY • The word “echocardiography” has a unique history. • Edler called the technique ultrasound cardiography(UCG). • In the early days of diagnostic ultrasound, the only examination that had any general popularity was detecting an echo from the midline of the brain to see if it was deviated by an intracranial space–occupying mass. This examination was known as echoencephalography. • If the ultrasonic examination of the brain was echoencephalography, then the examination of the heart should be echocardiography.
  21. 21. • The initial concern was that the natural abbreviation for echo- cardiography would be ECG. • Obviously, this abbreviation was already being used for electro - cardiography. • We could not use the abbreviation “echo” because it didn’t differentiate between echocardiography and echoencephalo- graphy. • The reason echocardiography was finally accepted as the name for this procedure was that echoencephalography disappeared. • Now, the abbreviation (echo) is only used for echocardiography. None of the other diagnostic ultrasonic procedures uses the word or term echo.
  22. 22. • In the 1960s, great progress was being made in developing real-time two-dimensional (2D) echocardiography. • In fact, it was the combination of sonar technology with advanced radar circuitry which improved ultrasonic instrument performance and introduced the prospect of 2D echocardiography. • After the early pioneering work of J. J. Wild and J. M. Reid and D. H. Howry and W. R. Bliss in the early 1950s, both European and Japanese investigators introduced real-time 2D instruments based on different principles.
  23. 23. • The first real-time, two- dimensional scanner that gained popularity was developed by Bom at Rotterdam. • This was a linear scanner, and it produced images that were like seeing the heart through a venetian blind. • This development was a breakthrough because it had demonstrated dramatically the potential of real-time, two- dimensional cardiac imaging and turned out to be one of the major ultrasonic scanning devices for non cardiac uses.
  24. 24. Photograph of a multielement transducer that provides an electronic linear scan and represents the first real-time, two-dimensional, echographic system (from Bom et al52 ). Harvey Feigenbaum Circulation. 1996;93:1321-1327 Copyright © American Heart Association, Inc. All rights reserved.
  25. 25. • It is somewhat ironic that the linear scanner, which is one of the most popular diagnostic ultrasound devices in general ultrasound, is almost never used for the organ for which it was designed, the heart. • Griffith and Henry at the National Institutes of Health came up with a mechanical device that rocked the transducer back and forth in a somewhat awkward fashion. It was handheld, but the ability to manipulate the transducer was very limited.
  26. 26. A)Two-dimensional sector mechanical device using a single crystal developed by Griffith and Henry. B) Two dimensional image of the short-axis aortic valve from that system. Ao indicates aorta; AoV, aortic valve; LA, left atrium; andRV, right ventricle.
  27. 27. • In 1968 R. Gramiak and P. M. Shah described contrast echocardiography, an accidental observation during indocyanine green injections for cardiac out put measurement. • This technique was extremely helpful in further identifying and delineating the various cardiac structures and is presently being refined for myocardial perfusion studies.
  28. 28. • In the early 1970s, Reggie Eggleton put a Sunbeam® electronic toothbrush to an innovative use and gave the world its 1st commercially successful 2 - dimensional echocardiogram for several years which enabled the visualization of actual images of the heart.
  29. 29. Photograph of an early real-time sector scanner that originated as a modified electric toothbrush. Harvey Feigenbaum Circulation. 1996;93:1321-1327 Copyright © American Heart Association, Inc. All rights reserved.
  30. 30. • The practical use of these instruments, however, was limited because of the need for a water bath contact, limited frame rates and large size transducers. Indeed, the small precordial acoustic windows to the heart dictate the use of a small transducer. • The large footprint of the bulky transducer was also the problem of the linear array system developed at the Thoraxcentre, but the clinical results with this instrument nevertheless stimulated the interest of cardiologist
  31. 31. • It was during the 1970s when the expanding interest in echocardiography led to striking advances in instrumentation. • Hence, much effort was expended to transfer continuous M- mode data to multichannel recorders, which would produce long, continuous strips of the recorded data • In keeping with the advances in instrumentation, transducer design began assuming greater importance.
  32. 32. (A) Sonographer Joan Korfhagen examining a neonate with an old Hoffrel unit. Note the reel-to-reel videotape equipment at the bottom of the Hoffrel unit, which then could transfer M-mode data to a multichannel strip chart recording (B). EN indicates endocardium; LS, left septum; and MV, mitral valve
  33. 33. • In 1968, J. Somer had constructed the first electronic phased- array scanner based on the wave-front theory formulated in the 17th century by C. Huygens and sonar technology • In 1974 F. J. Thurstone and O. T. von Ramm constructed their electronic phased-array scanner similar to the instrument developed by J. Somer. • This instrument marked the beginning of the revolutionary impact of ultrasound on clinical cardiology • Today, phased-array scanners are the most widely available imaging instruments and have a greater impact on cardiac diagnosis than electrocardiography, for which Einthoven was awarded the Nobel prize in 1924
  34. 34. • The Austrian C. A. Doppler (1803-1853) worked out the mathematical relationship between the frequency shift of sound and the relative motion of the sound source and the observer, a theory tested in practice in 1845 by C. H. D. Buys Ballot (1817 - 1890) in Utrecht DOPPLER ECHOCARDIOGRAPHY
  35. 35. • Investigation of blood flow velocity using Doppler frequency shifts to measure motion of cardiac structures, and later of the velocity of red blood cells, started with the work of S. Satomura and his colleagues in 1957. • The pulsed-wave Doppler technique was almost simultaneously introduced by P. N.T. Wells,P. A. Peronneau et al. and D. W.Baker • The method allowed depth selection for blood flow velocity interrogation, but the major step forward for its clinical acceptance was its combination with imaging: the duplex scanner published by F. E. Barber et al. in 1974 • This development ultimately led to the integration of pulsed- wave Doppler with 2D phased-array systems and allow blood flow to be studied at selected regions within the image plane.
  36. 36. • The Bernouilli equation is now the cornerstone of the Doppler assessment of cardiac haemodynamics and was published by the Dutch born D. Bernouilli (1700- 1782) in his treatise ‘Hydrodynamica’ in 1738. • He had formulated the relationship of the pressure drop across the inlet of an obstruction in a flow channel to the flow rate through it.
  37. 37. • Simultaneously, another major breakthrough in Doppler came in 1979, when Holen and then Hatle noted that a modified Bernoulli equation could be used to detect pressure gradients across stenotic valves and demonstrated that hemodynamic data could be accurately determined with Doppler ultrasound—the long-standing notion that cardiologists learn hemodynamics in the catheterization laboratory was suddenly changed. • In 1978, the Swiss-born M. A. Brandestini et al. produced a 128-channel digital multigate Doppler instrument, allowing the imaging of cardiac structures and blood flow in colour and in real-time
  38. 38. • Based on similar principles, C. Kasai et al. constructed in 1982 the revolutionary colour Doppler flow imaging system based on auto correlation detection, providing a non-invasive angiogram Of normal and abnormal blood flow on a ‘beat-to- beat’ basis. • At present, M-mode, 2D, pulsed-wave, continuous-wave and colour Doppler flow are all combined in one diagnostic console, and represent the most comprehensive cardiac diagnostic modality by providing integrated structural, functional and haemodynamic information
  39. 39. A. Early duplex scanner combining 2- dimensional and Doppler imaging. B. Typical pulsed Doppler data from early scanners.
  40. 40. TRANS ESOPHAGEAL ECHOCARDIOGRAPHY • Although the idea of transesophageal ultrasound to circumvent chest wall problems dates back to the early 1970s, clinical application started with anaesthetists using a M-mode system introduced by L. Frazin et al. in 1976 • The Japanese engineer K. Hisanaga and co-workers first reported transesophageal 2D imaging with a mechanical scanning system 1 year later. • The mono- and biplane electronic phased-array probes developed by J. Souquet in 1982 and his multiplane probe in 1985 represented the definitive clinical breakthrough of transoesophageal echocardiography
  41. 41. Examples of transesophageal phased array element transducers mounted on endoscopes.
  42. 42. INTRCARDIAC ECHOCARDIOGRAPHY • As early as 1960, T. Ciezynski mounted a single element transducer on a catheter to obtain intracardiac echocardiograms, and 3 years later R. Omoto obtained intracardiac 2D images with a slowly rotating, single-element transducer mounted at a catheter tip. • Two years later, N. Bom et al. described a real-time intracardiac scanner using an electronically phased circular array of 32 elements at the tip of a 9F catheter. • These developments were discontinued because of limitations of miniaturization and the striking improvements in precordial image quality making intracardiac imaging unnecessary.
  43. 43. • Early in the 1980s, cardiothoracic surgeons added echocardiography to their armamentarium when Marcus and associates developed the use of the epicardial Doppler crystal, which could be affixed to a coronary artery at the time of cardiac surgery to evaluate the physiologic significance of coronary stenosis in human beings. • This technique, together with transesophageal echocardiography, was subsequently used for the intra operative monitoring of the repair and replacement of heart valves, for the assessment of corrected congenital defects, and for the monitoring of wall-motion abnormalities.
  44. 44. 3D ECHOCARDIOGRAPHY • Since the early 1970s numerous investigators Dekker et al, Matsumoto et al, Geiser et al, Ghosh et al, Nixon et al,Snider et al, have explored the feasibility of three-dimensional (3D) echocardiography. • New computer technologies recently have made volume rendered data which make the display of tissue information possible even in real-time • .In the coming years this modality will further strengthen the diagnostic capabilities of cardiac ultrasound.
  45. 45. Static image of gated 4-dimensional fetal heart image acquisition: left, 4-chamber view; right, volume-rendered interior of the 4 chambers in the same orientation. LA indicates Left atrium; LV, left ventricle; RA, right atrium; and RV, right ventricle. (courtesy of Thomas R. Nelson, Department of Physics and Engineering, University of California, San Diego, CA).
  46. 46. • In the early days, it could take days for us to reproduce 3- dimensional images • Today it is possible to produce real-time 3 dimensional images that are believable by using an electronic array consisting of thousands of closely packed crystals. • Finally, intravascular cardiac ultrasound has become almost routine in some laboratories and investigative in some but is probably unavailable in others.
  47. 47. • Most of the applications have been dedicated to intracoronary evaluations. • Much of the early work was performed by Nissen et al as well as by others in adults. • It has even been used in pediatric patients who have undergone transplantation or had Kawasaki disease as well as in most other structures. • Again, as the technology improves in association with 3-D capabilities, it may become more important in the armamentarium of the cardiologist.
  48. 48. Examples of intravascular ultrasound catheters.
  49. 49. In this short history of cardiac ultrasound, credit is given to the pioneers of this exciting non-invasive and cost-effective diagnostic modality. Because of its versatility of application in a wide variety of health care environments, the technique will continue to grow along with advances in digital techniques and miniaturization.
  50. 50. Obviously, within the scope of this presentation , only the tip of the iceberg of echocardiography regarding the past, present, and even the future can be presented. So much more can be anticipated. The potential of ultrasonic application is limitless, and the evolution of echocardiography has been dramatic, to say the least…
  51. 51. Thank you

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