2. Contrast consists of microbubbles
that when mixed with red blood cells
in the cardiac chambers increase the
scatter of the ultrasonic signal,
therefore enhancing the blood–tissue
interface.
3. INDICATIONS
• Reduced image quality with ≥2 wall segments
not visualized
• Increase the accuracy of ventricular volume
measurement
• Stress testing for enhanced endocardial edge
detection
• Doppler signal enhancement
• Evaluation for left ventricular (LV) thrombus, LV
aneurysm
• Intracardiac masses
4. CONTRAINDICATIONS
• Pregnant or lactating women
• Patients who have known allergic
reaction to perflutren(octafluoropropane
gas)
• Right-to-left, bidirectional, or transient
right-to-left cardiac shunts
• Sensitivity to blood,blood products, or
albumin.
5. Two-syringe and three-way stopcock apparatus
for preparation of agitated saline contrast for
intravenous injection. The total volume in the
syringe on the left is approximately 10 mL, which
consisted initially of 9.5 mL of saline and 0.5 mL
of air.
6. Effective right heart contrast can be
obtained by forcefully agitating a
solution of saline between two 10-mL
syringes, each of which contains 5 mL
of saline and 0.1 to 0.5 mL of air
7. IMAGING MODALITIES FOR CONTRAST DETECTION
B-mode
Fundamental
Harmonic
High mechanical index
Low mechanical index
Continuous
Doppler
Harmonic versus fundamental
Frequency shift
Power spectrum
Correlation techniques
Continuous
Acquisition Mode
Triggered
Fixed interval
Variable, incremental interval
Triggered sequential
8. A: Apical four-chamber view
recorded in a patient after
injection of saline into a left
upper extremity vein.
B: After injection of intravenous
contrast, there is uniform
opacification of the right atrium
and right ventricle
9. After intravenous injection, these
early contrast agents were isolated
to the right heart and did not
traverse the pulmonary circuit. As
such, their appearance in the left
heart was evidence of a right-to-
left shunt.
10. CONTRAST AGENTS
Contrast agent consists of saline
microbubbles. Effective right heart contrast
can be obtained by forcefully agitating a
solution of saline between two 10-mL
syringes, each of which contains 5 mL of
saline and 0.1 to 0.5 mL of air.
11. By analyzing the timing and location of
appearance, the nature of this shunt can often
be determined as being a patent foramen
ovale, atrial septal defect (ASD), or pulmonary
arteriovenous malformation (AVM).
12. Safety of Ultrasound Contrast
Contrast echocardiography using both agitated saline and
commercially developed agents for left ventricular
opacification have had an excellent safety record.
The major concern regarding agitated saline is that
microbubbles of highly variable size subject to coalescence,
and that if present in the arterial circulation could result in a
clinical syndrome of air embolization.
There have been only infrequent isolated case reports of
neurologic or other sequelae following saline contrast
injection.
14. DETECTION METHODS
Interaction of microbubbles with ultrasound is
complex and can be divided into three types of
interaction: fundamental reflection, harmonic
creation and detection, and stimulated acoustic
emission.
15. Applications CAD
• Risk area or infarct size with MI
• Reperfusion efficacy
• No‐reflow phenomenon
• Myocardial viability
• Coronary collateral flow
• Coronary artery stenosis
• Coronary flow reserve
• Targeted marker or drug delivery
16. CLINICAL USES OF CONTRAST ECHOCADIOGRAPHY
The use of contrast echocardiography can be
divided into five broad categories:
(1)detection of intracardiac shunts
(2) left ventricular opacification for chamber
delineation .
(3)Refined definition of left ventricular
structural abnormalities
(4) Myocardial perfusion
(5) enhancement of Doppler signals.
17. Apical four-chamber
view in a patient with
a secundum atrial
septal defect.
Contrast in the left
ventricle but the
absence of contrast
in the more superior
portion of the left
atrium,reveals
diminished left
ventricular contrast
consistent with the
phasic nature of the
shunt in an atrial
septal defect.
18. Contrast Recording Techniques
• Non‐destructive- low energy,multipulse
• Real‐time, motion
• Ease of use
• Less sensitivity
• Non‐linearity methods
• Pulse inversion
• Power modulation
• Coherent imaging
• Destructive high energy, unipulse
• Most sensitive
• Triggered, no motion
• Can get tissue signals
• Power Doppler
• Ultraharmonics
19. Apical four-chamber view
recorded after saline contrast
injection in a patient with a
sinus venosus atrial septal
defect. The central image
was recorded immediately
after appearance of contrast
in the right atrium and shows
concurrent early appearance
in the left atrium, prior to its
appearance in the right
ventricle. This would be
consistent with sinus venosus
defect.
21. Apical four-chamber
view recorded in a
patient after injection
of saline into an upper
extremity vein. Note
the area of absent
contrast effect (large
arrow) along the most
superior portion of the
atrial septum.
22. Contrast Artifacts
Contrast artifacts can be divided into two broad
categories: those due to the agent and its interaction with the
ultrasound beam, and physiologic artifacts, both of which
may interfere with interpretation-
Agent/ultrasound related
Attenuation
Shadowing
Apical destruction
Physiologic
Competitive flow
SVC–IVC
Marginated flow
Incomplete blood pool mixing
Eustachian valve
23. Apical four-chamber
view recorded after
intravenous injection of
a perfluorocarbon-
based contrast agent
for the purpose of
myocardial perfusion
echocardiography.
30. Absorption of pulmonary veins
into the left atrium. At first only
one vein from the lungs enters
the left atrium. The proximal
part of the vein is gradually
absorbed and is incorporated
into the wall of the atrium. As a
result of continued absorption of
tributaries, four veins (two right
and two left) finally open into
the atrium
32. The right and left ventricles are formed by partitioning of
primitive ventricle and incorporation of bulbus cordis.
Bulbus Cordis
The bulbus cordis is the cranial most part (arterial end) of the
developing heart tube. It is divisible into three parts,
(1) proximal, (2) middle and (3) distal. The proximal one-third
is dilated and does not have any special name; the middle
one-third is called the conus, and the distal one-third is
called the truncus arteriosus.
33. Bulboventricular cavity consists of:-
•A dilated lower part (1) that communicates with the
atria
• A conical upper part (2) communicating with the
truncus arteriosus.
• Part “1” is derived from the proximal one-third of
the bulbus cordis and the primitive ventricle, while
part “2” is from the conus.
35. Two parts of the
ventricular chamber.
Part 1 lies anterior to
the atrioventricular
orifice.
Part 2 is conical and lies
higher up.
A section across the
ventricle in the
plane XY, shown in.
Sections in the plane
indicated by the
arrow in
Aorticopulmonary/
spiral septum
36. The proximal one-third of the bulbus cordis
merges with the cavity of the primitive ventricle
and forms the bulboventricular chamber. It takes
part in forming the trabeculated part of the right
ventricle.
37.
38. Persistent A-V canal
• Failure of A-V endocardial cushions to fuse
• Common in Down syndrome View of A-V canal looking down into
ventricles with atria removed
(e.g. at dotted line on left)
39. Formation of Interventricular Septum
The interventricular septum consists of three
parts that
develop from different sources.
(1) muscular
(2) bulbar and
(3) membranous part
40. Bulbar septum grows down
from above, and interventricular
septum grows upward from
below; The gap between
the bulbar septum and the
interventricular septum is filled
in by proliferation from AV
cushion
41. Interior of bulboventricular
cavity showing the cephalic
margin of interventricular
septum and its two horns and
the proximal bulbar septum
formation
42. The interventricular septum is probably formed
more by downward enlargement of the right and
left ventricular cavities on either side of the
septum, rather than by active growth of the
septum itself.
43. Interatrial and
interventricular
septa do not meet
the atrioventricular
(AV) cushions in
the same plane.
The first part separates the left
ventricle from the right atrium while
the second part separates the two
ventricles. The tricuspid valve is
attached to the membranous septum
at the junction of these parts.
45. Right and Left Ventricles
They are formed by:
•The inflow (rough) parts of both ventricles are formed
by corresponding parts of primitive ventricle.
•The outflow parts (smooth parts), i.e. infundibulum of
right ventricle and aortic vestibule of left ventricle are
formed by the middle one-third of the bulbus cordis
only, i.e. the conus. The conus forms the outflow tracts
(smooth parts) of both the right and left ventricles
46. VALVES OF THE HEART
The mitral and tricuspid valves are formed by
proliferation of connective tissue under the endocardium of
the left and right AV canals.
The pulmonary and aortic valves are derived from
endocardial cushions that are formed at the junction of the
truncus arteriosus and the conus .
47.
48. With the separation of the aortic and pulmonary
openings, the right and left cushions are each subdivided into two parts,
one part going to each orifice Simultaneously, two more cushions, anterior and
posterior appear.
• As a result,the aortic and pulmonary openings each have three cushions
from which three cusps of the corresponding valve develop.
• The pulmonary valve is at first ventral to the aortic valve
• Subsequently,there is a rotation so that the pulmonary valve comes to lie
ventral and to the left of the aortic Valve.
• It is only after this rotation that the cusps acquire their definitive
relationships (Pulmonary trunk: 1 posterior, 2 anterior; Aorta: 1anterior,
2 posterior).
49.
50. Formation of aortic and pulmonary valves.
Vessels undergo an anticlockwise rotation. It is only after
this rotation that the cusps of the aortic and pulmonary
valves acquire their definitive position
51. Formation of AV valves
dependent on AV cushions and ventricular myocardium…
52. A
P
L
R
Formation of semilunar valves
Truncoconal
septum
Mitral valve
Tricuspid
valve
Pulmonary
valve
tubercles
Pulmonary
artery
Aorta
also outflow cushion dependent…
53. PERICARDIAL CAVITY
The pericardial cavity is a derivative of the part of the
intraembryonic coelom that lies in the midline, cranial
to the prechordal plate
The parietal layer of the serous pericardium, and the
fibrous pericardium, are derived from the somatopleuric
mesoderm lining the ventral side of the pericardial
Cavity.
The visceral serous pericardium is derived from the
splanchnopleuric mesoderm lining the dorsal side of
the pericardial cavity
54. Relationship of the heart tube
to the pericardial sac. (A),
(B) and (C) are lateral views
while (D), (E) and (F) show
the dorsal aspect of the
interior of the pericardial sac
at corresponding stages.
Disappearance of the
mesocardium leads to
formation of the transverse
sinus of pericardium
PERICARDIAL CAVITY
58. CONDUCTING SYSTEM OF THE HEART
• At stage when there are two heart tubes, a pacemaker
(which later forms the sinoatrial node) lies in the caudal part
of the left tube.
• After fusion of the two tubes, it lies in the sinus venosus.
•The AV node and the AV bundle form in the left wall of the
sinus venosus, and in the AV canal.
•After the sinus venosus is absorbed into the right atrium, the
AV node comes to lie near the interatrial septum.
61. R
L
5th wk
8th wk 9th wk
7th wk
Truncoconal ridges
• Neural crest-derived endocardial cushions
form in truncus arteriosis and conus
(bulbus) cordis region
• Fuse at truncoconal transition and “zip”
proximally and distally to form
aorticopulmonary septum.
Outflow Tract Partitioning
Membranous septum formed by contributions
from AV cushions and truncoconal cushions.
QuickTime version
62. Outflow Tract Defects
• Typically due to failure of neural crest-derived
conotruncal cushions
• Associated with other disorders affecting neural crest:
DiGeorge syndrome, fetal alcohol syndrome,
chromosome 22 mutations (e.g. Tbx-1)
• Can also arise due to defects in secondary heart field
(e.g. Hand-2, retinoids)
• Examples include: persistent truncus arteriosus,
transposition of the great vessels, aortic and/or
pulmonary stenosis (tetrology of Fallot)
65. Pulmonary Stenosis: Tetrology of Fallot
• Pulmonary stenosis
• Overriding aorta
• Intraventricular septal defect
• Hypertrophy of right ventricle
• (Patent ductus arteriosus)… so really a “pentology”
Carlson fig 17-40
66. Mitral stenosis/hypoplastic left ventricle
• Failure of left A-V valve (tricuspid
valve) to form: LV and aorta becomes
hypoplastic because of reduced load.
• OK in embryo since oxygenated blood
is coming from IVC and can be
distributed systemically via ductus
arteriosus.
• But, this arrangement doesn’t work so
well in a breathing infant since
oxygenation occurs in the lungs.
67. Why is a right-left shunt necessary?
In the fetus, blood is oxygenated in the placenta and
delivered to the heart via the inferior vena cava:
• Shunted to left atrium via foramen ovale
• Also shunted from pulmonary outflow via ductus
arteriorsus
71. Changes in the aortic arch pattern (AS,1,2,3,5)
5th arch fails to form
2nd arch mostly disappears
• stapedial a.
• (hyoid a.?)
3rd arch:
• common carotid a.
• part of internal carotid a.
• internal and external
carotid aa. sprout from 3rd arch
Aortic Sac (AS):
• proximal part of aortic arch
• brachiocephalic a.
1st arch mostly disappears
• maxillary a.
• (part of external carotid a.?)
Aortic sac
72. Changes in the aortic arch pattern (4)
4th arch on left:
– arch of aorta
(from left common carotid a.
to left subclavian a. only)
4th arch on right:
– proximal segment of right
subclavian a. (rest of subclavian
a. from 7th intersegmental a. and
R dorsal aorta)
73. Changes in the aortic arch pattern (6)
(6th arch = pulmonary arch)
6th arch on left:
– left pulmonary artery
– distal segment persists as ductus arteriosus
6th arch on right:
– right pulmonary artery
– distal segment regresses
74. Aortic Arch
Anomalies
(A) Double aortic arch
abnormal persistence of right
distal segment
~1:1000 incidence –often assoc.
with dysphagia and/or dyspnea
(B) Right aortic arch
abnormal persistence of right
distal segment & regression of left
distal segment
~1:1000 incidence –usually
asymptomatic
(C) Aberrant right subclavian
(from aortic arch)
(abnormal regression of right
proximal segment & persistence
of right distal segment)
~1:100 incidence –often assoc.
with dysphagia and/or dyspnea;
also, R radial pulse may be weak
normally
regresses
normally
persists
normally
persists
75. Interrupted aortic arch (IAA)
• Abnormal regression of proximal left 4th arch
• Output to left upper limb, trunk, and both lower limbs is via pulmonary trunk (connected to
descending aorta via ductus arteriosus)
• Rather asymptomatic at first, but ductus starts to close during first 2 weeks of life, so needs to
be caught and fixed (via surgical reconstruction) by then
• Neural crest etiology: Rare (1:50,000) in general population, but rather common (~10%) in
patients with DiGeorge syndrome (22q deletion)
Carlson fig 17-44
L subclavian a.
R subclavian a.
R and L common
carotid arteries
and right limb*
*The R subclavian is
shown here as a separate
branch from the arch of
the aorta; the middle
vessel is the R common
cartotid; the remaining
vessel coming from the
arch of the aorta is the L
common carotid.
76. Adult derivatives Embryological structures
Ascending aorta - Truncus arteriosus
Arch of aorta- Aortic sac,left horn of aortic sac&left4tharch
artery
Descending aorta- Left dorsal aorta and fused dorsal aorta
Brachiocephalic artery - Right horn of aortic sac
Right subclavian artery - Right 4th arch artery and 7th
cervicalintersegmental artery
Left subclavian artery - Left 7th cervical intersegmental
artery
Common carotid artery- Proximal part of 3rd arch artery
Internal carotid artery - Distal part of 3rd arch artery and
cervical part of dorsal aorta
External carotid artery- As a bud from 3rd arch artery
Pulmonary trunk- Truncus arteriosus
Pulmonary artery- Part of 6th arch artery
Ductus arteriosus - Part of left 6th arch artery
77. Coarctation of aorta
• Collateral circulations
can compensate for
postductal coarctation
– But, not perfect, so blood
pressure in upper limbs is
higher compared to lower
limbs
• Preductal coarctation is
MUCH less common (5% of
coarctations)
~1:3000 incidence overall, but
commonly coincident w/
Turner’s syndrome (~20%) and
neural crest disorders
81. Vitelline and umbilical veins change
during liver development
• R hepatocardiac channel
hepatic portion of IVC
• R umbilical V regresses
• proximal L umbilical V regresses
• distal L umbilical V persists
and then round ligament of the liver (ligamentum teres hepatis)
• ductus venosus ligamentum venosum
L vitelline V
umbilical V
sinus
venosus
cardinal V
hepatic
sinusoids
duodenum
duodenum
yolk sac
L hepatocardiac
channel
R hepatocardiac
channel
ductus
venosus
portal V
superior
mesenteric V
splenic V
hepatic portion of
inferior vena cava
hepatic V
(R vitelline V) hepatic V
4 weeks 5 weeks
6 weeks
8 weeks
Langman’s fig 12-42
84. Veins of the embryo are categorized into two groups
All drain into sinus venosus.
1. Visceral veins
–– Vitelline
–– Umbilical veins—placenta
2. Somatic veins
–– Cardinal veins.
Interconnections between the veins lead to establishment
of shortest hemodynamic route by regression and/or
enlargement of some veins. This results in the formation of
major system of veins of adult.
• Portal system
• Caval system
• Azygos system.
85. Fate of anterior cardinal veins, and the development upper
part of the body
88. A) Veins from the body wall draining into anterior and
posterior cardinal veins; (B) With the formation of the
azygos venous channel (Az), most of the veins of the body
wall now drain into it.
(C) Shows the ultimate arrangement. Note
that veins from the 1st intercostal space drain into the
innominate veins directly (anterior cardinal). The veins of
the left 2nd and 3rd spaces drain into the left superior
intercostal vein which is formed partly by the anterior
cardinal and partly by the posterior cardinal.
89. Development of the inferior vena cava.
Subcardinal veins-green;supracardinal veins orange,
subcardinal-hepatocardiac anastomosis yellow;
the hepatocardiac channel itself is purple
supracardinal-subcardinal anastomosis is brown. The
inferior vena cava receives contributions from each of these
components as indicated by the color in(D)
(D
92. Anomalies of the inferior vena cava.
(A) Shows the normal pattern while (B), (C) and (D) show
various types ofduplication of the infrarenal segment.
(E) the normal infrarenal segment is absent and is replaced
by a vessel on the left side;
(F) Absence of the hepatic segment of the vena cava, the
blood flow taking place along a much enlarged vena
azygos;
(G) Shows the normal pattern
93. Development of the umbilical artery (A) Umbilical arteries are
seen as continuations of the right and left dorsal aortae (B) After
fusion of dorsal aortae, the umbilical arteries appear as lateral
branches of the aorta. They cross the 5th lumbar intersegmental
artery(C)Umbilical arteries establish anastomoses with the 5th
lumbar intersegmental artery(D) The part of the umbilical artery
between the dorsal aorta and the 5th lumbar intersegmental
artery disappears;and the umbilical artery is now seen as a
branch of the latter (E) The 5th lumbar intersegmental artery
forms the common iliac and internal iliac arteries; and the
umbilical is now seen as a branch of the internal iliac
94.
95. Development of arteries of upper limb
–– Axillary artery
–– Brachial artery
–– Anterior interosseous artery
–– Deep palmar arch.
96. Artery of the Lower Limb- Derived from the fifth lumbar intersegmental artery.
•The femoral artery is a new vessel formed on the ventral aspect of the thigh.
•Proximally
– Inferior gluteal artery
– Part of the popliteal artery
–Distal part of the peroneal artery
– Part of the plantar arch.
97. Derivation of the coronary sinus and related structures
1 and 7 = right and left anterior cardinal veins.
2 and 8=posterior cardinal veins;3 and 6=common cardinal
4 and 5=right and left horns of sinus venosus
9=right vitelline vein.
Fate of these structures is shown in-II
1a+3a=superior vena cava;2a=terminal part of the azygos
4a=part of right atrium;5a and proximal half ,6a = coronary
sinus; distal half of 6a=oblique vein of left atrium;7a + 8a =
left superior intercostal vein;9a=inferior vena cava
98. FETAL CIRCULATION
Placenta: Gaseous exchange takes place.
Umbilical vein: Oxygenated blood from the placenta comes
to the fetus through the umbilical vein, which joins the left
branch of the portal vein.
Ductus venosus: It is for bypassing hepatic circulation.
A sphincter mechanism in the ductus venosus controls
blood flow.
100. •Foramen ovale:
It connects the two atria. The oxygen rich
blood reaching the right atrium through the inferior
vena cava is directed by the valve of the inferior vena
cava toward the foramen ovale. Here it is divided into
two portions by the lower edge of the septum secundum
(crista dividens):
1. Most of it passes through the foramen ovale into the
left atrium.
2. The rest of it gets mixed up with the blood returning
to the right atrium through the superior vena cava,
and passes into the right ventricle.
101. Ductus arteriosus
It is for bypassing pulmonary
circulation. From the right ventricle, the blood
(mostly deoxygenated) enters the pulmonary trunk. Only a
small portion of this blood reaches the lungs, and passes
through it to the left atrium.
102. Blood supply to fetus
left atrium receives blood from two sources the oxygenated
blood from the right atrium and a small amount of
deoxygenated blood from the lungs.
This blood passes into the left ventricle and
then into the aorta. Some of this oxygen-rich blood
passes into the carotid and subclavian arteries to
supply the brain, head and neck,upper
extremities. The rest of it gets mixed up with poorly
oxygenated blood from the ductus arteriosus.
103. Umbilical arteries: They carry deoxygenated blood from
fetus. Much of the blood of the aorta is carried by the umbilical
arteries to the placenta where it is again oxygenated and
returned to the heart.
Three times blood shunts along its course at:
Ductus venosus—to direct blood to inferior vena cava by
passing liver without losing oxygen content.
Foramen ovale—to equalize distribution to each half of heart
and more oxygenated blood to upper half vital organs
Ductus arteriosus—to direct blood to placenta for
oxygenation by passing lungs
104. Umbilical arteries
Proximal part—superior vesical artery
Distal part—fibrosed—medial umbilical ligament
Left umbilical vein -Ligamentum teres of the liver
Ductus venosus –Ligamentum venosum
Ductus arteriosus- Ligamentum arteriosum
