Echocardiography basics

Basic of
Echocardiography
Presented by:- Dr HIMANSHU SAMAIYA
Resident : SGMH Rewa M.P.
basic of echocardiography by dr.himanshu 1

INTRODUCTION
It is a type of ultrasound test that uses high pitched
sound waves to produce an image of the heart.
 The sound waves are sent through a device called a
transducer and are reflected off the various structures
of the heart.
 These echoes are converted into pictures of the heart
that can be seen on a video monitor.

COMPONENTS
 Pulse generator - applies high amplitude voltage to energize the
crystals
 Transducer - converts electrical energy to mechanical (ultrasound)
energy and vice versa
 Receiver - detects and amplifies weak signals
 Display - displays ultrasound signals in a variety of modes
 Memory - stores video display

INDICATION
 Cardiac chamber size and contents
 Ejection fraction
 Pericardial sac i.e. pericardial effusion, constrictive pericarditis
 Ascending aorta assessment of known or suspected adult congenital heart diease.
 Evaluation of suspected complication of myocardial ischemia/infarction.
 Evaluation of valvular or structural heart disease.
 Infective endocarditis
 Suspected tumor or thrombus
 Cardiomyopathy : dilated, restrictive, and hypertrophic
 Pulmonary hypertension

PROCEDURE
 A standard echocardiogram is also known as a
transthoracic echocardiogram (TTE), or cardiac
ultrasound.
 The subject is asked to lie in the semi recumbent position
on his or her left side with the head elevated.
 Ultrasound is transmitted from a transducer having a frequency
of 2.5 to 3.5 MHz for echo in adults.
 To study deep seated structures because of better penetration.
 A transducer frequency of 5.0 MHz is suitable for pediatric echo,
since the heart is more superficial in children

WINDOWS OF ECHO
 Evaluation of the heart with
echocardiography requires
"acoustic windows" of the heart.
 Bone reflects the ultrasound waves
and so all structures directly behind
bone are not visible with ultrasound.

Parasternal Long-Axis View
(PLAX)
Transducer position: left sternal
edge; 2nd – 4th intercostal space
Marker dot direction: points
towards right shoulder
Most echo studies begin with this
view
It sets the stage for subsequent
echo views
Many structures seen from this
view

Measurements in PLAX view can be used to quantify the
heart:
 Left ventricular size and wall thickness
 Left atrial linear dimension (as opposed to area)
 Left ventricular outflow tract diameter (used to
calculate aortic valve area by the continuity equation)
 Aortic annulus, sinus of Valsalva, and aortic root
sizes

Parasternal Short Axis View
(PSAX)
 Transducer position: left sternal edge;
2nd – 4th intercostal space.
 Marker dot direction: points towards left
shoulder(90˚ clockwise from PLAX view)
 By tilting transducer on an axis between
the left hip and right shoulder, short axis
views are obtained at different levels,
from the aorta to the LV apex.
 The aortic valve, right ventricular inflow
& outflow tracts visible with the tricuspid
valve

Papillary Muscle (PM)level
•PSAX at the level of the
papillary muscles showing how
the respective LV segments are
identified, usually for the
purposes of describing
abnormal LV wall motion
• LV wall thickness can also be
assessed

Apical 4-Chamber View (AP4CH)
• Transducer position: apex of
heart
• Marker dot direction: points
towards left shoulder
• The AP5CH view is obtained from
this view by slight anterior
angulation of the transducer
towards the chest wall.
• The LVOT can then be visualised

Apical 2-Chamber View (AP2CH)
• Transducer position: apex of the
heart
• Marker dot direction: points
towards left side of neck (45˚
anticlockwise from AP4CH view)
• Good for assessment of LV
anterior wall and LV inferior wall

Sub–Costal 4 Chamber View(SC4CH)
• Transducer position: under the
xiphisternum
• Marker dot position: points
towards left shoulder
• The subject lies supine with head
slightly low (no pillow). With feet
on the bed, the knees are slightly
elevated
• Better images are obtained with
the abdomen relaxed and during
inspiration
• Interatrial septum, pericardial
effusion, desc abdominal aorta

Suprasternal View
• Transducer position: suprasternal
notch
• Marker dot direction: points towards
left jaw
• The subject lies supine with the neck
hyperextended. The head is rotated
slightly towards the left
• The position of arms or legs and the
phase of respiration have no bearing
on this echo window
• Arch of aorta,ascending
aorta,pulmonary artery

TYPES OF ECHOCARDIOGRAPHY
Transthoracic echocardiography
Transesophageal echocardiography
Stress echocardiography
Three-dimensional echocardiography

TRANSESOPHAGEAL ECHOCARDIOGRAPHY
• The oesophagus in its mid-course is located posterior to the heart and
anterior to the descending aorta.
• This provides an opportunity to interrogate the heart and related
mediastinal structures with a high frequency transducer positioned in the
esophagus for better image resolution.
• The transducer to be inserted down the throat into the esophagus (the
swallowing tube that connects the mouth to the stomach).

Advantages of TEE
 Useful alternative to transthoracic echo in case of obesity, chest wall
deformity, emphysema or pulmonary fibrosis.
 Useful complement to transthoracic echo because of better image
quality and resolution due to two reasons:
 – absence of acoustic barrier between the ultrasound beam and the
rib cage, chest wall and lung tissue.
 – greater proximity to the heart and therefore the ability to use higher
frequency probe with vastly improved image quality and precise
spatial resolution. basic of echocardiography by dr.himanshu 18

 Useful supplement to transthoracic echo, which
cannot examine the posterior aspect of the heart.
 Structures such as left atrial appendage, descending
aorta and pulmonary veins can only be visualized by
TEE.
 very high sensitivity for locating a blood clot inside
the left atrium.

Disadvantages
 It takes longer to perform a TEE than a TTE.
 It may be uncomfortable for the patient.
 It requires short-term sedation, oxygen
administration and ECG monitoring since, there are
chances of hypoxia, arrhythmia and angina.
 TEE images require a comprehensive understanding
of the spatial relationship between cardiac structures.

Complications with TEE
Major :-
 Esophageal rupture or perforation
 • Laryngospasm or bronchopasm
 • Sustained ventricular tachycardia
Minor:-
 Retching and vomiting
 • Sore-throat and hoarseness
 • Blood-tinged sputum
 • Tachycardia or bradycardia
 • Hypoxia and ischemia
 • Transient BP rise or fall basic of echocardiography by dr.himanshu 21

Contraindications to TEE
 Unrepaired tracheoesophageal fistula
 History prior esophageal surgery
 Esophageal obstruction or stricture
 Perforated hollow viscus
 Gastric or esophageal bleeding
 Poor airway control
 Severe respiratory depression
 Oropharyngeal pathology
 Uncooperative, unsedated patient
 Severe coagulopathy
 Cervical spine injury

STRESS ECHOCARDIOGRAM
 A stress test accompanied by echocardiography.
 During a stress.echo, patient exercise on a treadmill or statio
nary bike with blood pressure and heart rhythm monitoring.
 The echocardiography is performed both before and after the
exercise to compare structural differences.
 To assess for any abnormalities in wall motion of the heart.
 This is used to detect obstructive coronary artery disease

Technique:
 NPO for four hours before the test.
 Do not drink or eat caffeine products (cola, chocolate, coffee, tea)
for 24 hours before the test.
 Do not take any over-the-counter medications that contain caffeine
for 24 hours before the test.
 Do not take the following heart medications for 24 hour before the
test unless doctor tells.
 *Beta-blockers * Isosorbide dinitrate
 *Isosorbide mononitrate *Nitroglycerin

DOBUTAMINE STRESS ECHOCARDIOGRAM
 A form of stress echocardiogram.
 The test is used to evaluate heart and valve function when
unable to exercise on a treadmill or stationary bike.
 Most dobutamine stress protocols start at an infusion rate
of 5 ug/kg/min and increase to a peak dose of 40
or 50 ug / kg / min.
 To further increase heart rate, a bolus injection of 0.25—
1 .0 mg atropine is added

INTRAVASCULAR ULTRASOUND
 A form of echocardiography performed during cardiac
catheterization.
 During this procedure, the transducer is threaded into
the heart blood vessels via a femoral catheter.
 Used to provide detailed information about the
atherosclerosis (blockage) inside the blood vessels.

THE MODALITIES OF ECHO
1. Conventional echo
 Two-Dimensional echo (2-D echo)
 Motion- mode echo (M-mode echo)
2 Doppler Echo
 Continuous wave (CW) Doppler
 Pulsed wave (PW) Doppler
 Colour flow(CF) Doppler

MOTION-MODE (M MODE) ECHO
 In the M-mode tracing, ultrasound is transmitted and
received along only one scan line.
 This line is obtained by applying the cursor to the 2-D
image and aligning it perpendicular to the structure
being studied.
 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.

 Since only one scan line is imaged, 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.
 Simultaneous ECG recording facilitates accurate timing of cardiac
events.
 Similarly, the flow pattern on color flow mapping can be timed in
relation to the cardiac cycle.

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

DOPPLER ECHOCARDIOGRAPHY
 Doppler echocardiography is a method for detecting the direction and
velocity of moving blood within the heart.
 PULSED WAVE (PW):
 useful for low velocity flow e.g. MV flow.
 PW Doppler transmits ultrasound in pulses and waits to receive the
returning ultrasound after each pulse.
 PW Doppler provides a better spectral tracing than CW Doppler, which is
used for calculations.
 PW Doppler modality is used to localize velocity signals and
 Abnormal flow patterns picked up by CW Doppler and color flow mapping,
respectively.

Continuous Wave (CW)
 Useful for high velocity flow e.g aortic stenosis
 CW Doppler transmits and receives ultrasound continuously
 This Doppler modality is used for rapid scanning of the heart in
search of high velocity signals and abnormal flow patterns.
 CW Doppler is 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.
 By using CW Doppler signal of the tricuspid valve, pulmonary artery
pressure can be calculated.

Color Flow (CF)
 It is also known as real-time Doppler imaging.
 Color Doppler provides a visual display of blood flow within the
heart, in the form of a color flow map.
 Different colors are used to designate the direction of blood
flow.
 Red is flow toward, and Blue is flow away from the transducer
with turbulent flow shown as a mosaic pattern. (BART)

Color flow map of a normal mitral valve from A4CH view
showing a red-colored jet

Color flow map of ventricular outflow tract from A5CH view
showing a blue jet

APPLICATIONS OF COLOR DOPPLER
Stenotic Lesions:
 Color Doppler can identify, localize and quantitate stenotic lesions of
the cardiac valves.
 It visually displays the stenotic area and the resultant jet as distinct
from normal flow.
Regurgitant Lesions:
 Color Doppler can diagnose and estimate the severity of regurgitant
lesions of the valves
Intercardiac shunts

THREE DIMENSION ECHO
 Future direction in echo
 Obviates the need for cognitive 3 D construction of 2
D image plane
 Useful in:-
1. ventricular volume assessment
2. Study of asymmetrical stenotic valve
3. Complex structural relationships in congenital
heart disease .

MYOCARDIAL CONTRAST ECHO
 Application of ultrasonic
contrast agent, to accurately
delineate areas of reduced
myocardial blood flow or
perfusion defect related to
coronary occlusion
 Contrast exist as microbubbles

Echo findings in Heart
diseases

DIALATED CARDIOMYOPATHY
 The ventricles are dilated more
than the normal.

HYPERTROPHIC CARDIOMYOPATHY
• The intra ventricular
septum appears thickened
• IVS:LVPW ratio >1.5

RESTRICTIVE CARDIOMYOPATHY
• Thick and bright septum
• Reduced size of ventricles
• Dilated RA and LA

LEFT VENTRICULAR HYPERTROPHY

CARDIAC TAMPONADE

INFECTIVE ENDOCARDITIS

MITRAL STENOSIS
• Thickening of valve leaflets
• Restricted opening of valve
• Dilatation of left atrium
• Diastolic doming of anterior
leaflets

MITRAL REGURGITATION
• Regurgitant jet in LA on
A4CH view.
• Extent of MR jet fills the LA
Cavity indicates severity of
MR.

VSD
ASD

LEFT ATRIAL CLOT LEFT VENTRICULAR CLOT

CORONARY ARTERY DISEASE

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