Echocardiography

1. ECHOCARDIOGRAPHY

2. DEFINITION
⦁ Echocardiogram is a diagnostic test which uses
ultrasound waves to make images of the heart
chambers, valves and surrounding structures. It can
measure cardiac output and is a sensitive test to find
fluid around the heart (pericardial effusion).

3. TYPES
Transthora
cic
echocardio
gram
Transesoph
ageal
echocardiog
ram
Stress
echocardiogr
am
Doppler
echocardi
ogram

4. TRANSTHORACIC ECHO
⦁ A transthoracic echocardiogram (TTE) is the most
common type of echocardiogram . In this case, the
probe (or ultrasonic transducer) is placed on
the chest or abdomen of the subject to get various
views of the heart.
⦁ It is used as a non-invasive assessment of the
overall health of the heart, including a patient's heart
valves and degree of heart muscle contraction (an
indicator of the ejection fraction).

5. TRANSTHORACIC ECHO

6. TRANSESOPHAGEAL ECHO(TEE)
⦁ A specialized probe containing an ultrasound
transducer at its tip is passed into the
patient's oesophagus.

7. Advantages of TEE
⦁ The advantage of TEE over TTE is usually clearer
images, especially of structures that are difficult to
view transthoracically (through the chest wall) since
heart rests directly upon the esophagus leaving only
millimeters that the ultrasound beam has to travel
⦁ This reduces the attenuation (weakening) of the
ultrasound signal, generating a stronger return
signal.

8. ⦁ In adults, several structures can be evaluated
and imaged better with the TEE, including
the aorta, pulmonary artery, valves of the heart,
both atria, atrial septum, left atrial appendage,
and coronary arteries.
⦁ TEE has a 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, who may
require sedation or general anesthesia.
⦁ Some risks are associated with the procedure,
such as esophageal perforation around 1 in
10,000, and adverse reactions to the medication.

9. PROCESS OF TEE
⦁ Before inserting the probe, mild to
moderate sedation is induced in the patient to ease
the discomfort and to decrease the gag reflex, thus
making the ultrasound probe easier to pass into the
esophagus.
⦁ Mild to moderate Sedation is produced
by midazolam (a benzodiazepine ) , fentanyl (an
opioid) or propofol
⦁ Usually a local anesthetic spray is used for the back
of the throat, such a xylocaine /or a jelly /lubricant
anesthetic for the esophagus.
⦁ Children are anesthetized

10. CLINCAL USE S
⦁ TEE can be performed by a cardiac anesthesiologist
to evaluate, diagnose, and treat patients in the
perioperative period.
⦁ . TEE is very useful during many cardiac surgical
procedures (e.g., mitral valve repair and in aortic
dissections). It is actually an essential monitoring
tool and to assess the results of surgery immediately
after the procedure.

11. STRESS ECHOCARDIOGRAM
⦁ A stress test may be accompanied
by echocardiography.
⦁ The echocardiography is performed both before and
after the exercise so that structural differences can
be compared.
⦁ A resting echocardiogram is obtained prior to stress.
⦁ The images obtained are similar to the ones
obtained during a full surface echocardiogram,
commonly referred to as transthoracic
echocardiogram.

12. ⦁ The patient is subjected to stress in the form of
exercise or chemically (usually dobutamine).
⦁ After the target heart rate is achieved, 'stress'
echocardiogram images are obtained.
⦁ The two echocardiogram images are then compared
to assess for any abnormalities in wall motion of the
heart. This is used to detect obstructive coronary
artery disease.

14. Doppler echocardiography
⦁ Doppler echocardiography is a procedure that
uses Doppler ultrasonography to examine
the heart. An echocardiogram uses high frequency
sound waves to create an image of the heart while
the use of Doppler technology allows determination
of the speed and direction of blood flow by utilizing
the Doppler effect.
⦁ Velocity measurements allow assessment of cardiac
valve areas and function, any abnormal
communications between the left and right side of
the heart, any leaking of blood through the valves
(valvular regurgitation), calculation of the cardiac
output and calculation of E/A ratio(a measure
of diastolic dysfunction).

15. ADVANTAGES OF DOPPLER
⦁ An advantage of Doppler echocardiography is that it
can be used to measure blood flow within the heart
without invasive procedures such as cardiac
catheterization.
⦁ The method can measure tissue velocities by tissue
Doppler echocardiography.
⦁ The combination of flow and tissue velocities can be
used for estimating left ventricular filling pressure,
although only under certain conditions

16. DOPPLER ECHO

17. Doppler Echo
An abnormal echocardiogram : Image shows a
midmuscular ventricular septal defect. The trace in the
lower left shows the cardiac cycle . Colors are used to
represent the velocity and direction of blood flow.

18. AXES IN ECHOCARDIOGRAPHY
Two key axes of the heart are the long axis and short
axis.
⦁ The long axis is an imaginary line from the apex of
the heart through the centre of the mitral valve.
⦁ The short axis is perpendicular to the long axis and
shows the heart in cross section.

19. 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.
⦁ This requires that the heart be viewed between
bones and, in particular, between ribs. The most
common views are the parasternal, apical,
subcostal, and suprasternal windows.

20. 🞂 Para sternal:
Adjacent to the sternum..
⦁ Apical:
At the apex of the heart.
⦁ Sub costal:
Below the sternum at the top of the abdomen
⦁ Supra sternal:
Above the sternal at the base of the neck

21. VIEWS
⦁ There are several typical views
obtained during a routine TTE. Views
outside of the typical views can be
considered "off axis" and may be
obtained for specific purposes.

22. Parasternal long axis (PLAX)
⦁ This view is obtained to the left of the sternum and
views the heart in its long axis. In this view, the mitral
valve, aortic valve, right ventricular outflow tract,
base of the left ventricle, and the left atrium can be
visible.
⦁ In this view, it is possible to appreciate the long-axis
cross section of the mitral and aortic valves. The
classic "hockey stick" shape of rheumatic mitral
stenosis can be appreciated in this view.
⦁ The parasternal long view of the pulmonary valve is
the only view of the posterior leaflet.

23. PLAX

24. Structures visible:
⦁ Anterior septal and inferior lateral walls of the left
ventricle
⦁ Left atrium
⦁ Mitral valve in long-axis with chordae
⦁ Aortic valve in long-axis
⦁ Tricuspid valve in long-axis (angulated) and right
ventricular inflow tract
⦁ Pulmonary valve in long-axis (angulated) and right
ventricular outflow tract

25. Measurements in this 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
⦁ Color doppler of all four valves
⦁ Spectral doppler of tricuspid and pulmonary valves

26. Parasternal short axis (PSAX)
⦁ This view is obtained in the same window as the
parasternal long, but with the probe rotated 90°.
⦁ In this view, the aortic valve is seen in cross-section
with the right ventricular inflow & outflow tracts
visible with the tricuspid valve as well
⦁ . Pulmonary valve is not visible in this view. Both the
right and left atria are visible.
⦁ The standard PSAX view is at the level of the aortic
valve, but moving the probe along the long-axis can
review the LV outflow tract, LV at the base, and LV at
the mid section.

27. PSAX

28. Structures visible:
⦁ Aortic valve in short-axis
⦁ Aortic valve dysfunction, aortic sclerosis/stenosis
⦁ Tricuspid valve in long-axis
⦁ Right ventricle including inflow and outflow tracts
⦁ Left ventricle in short-axis
⦁ Closer to the base can reveal the left ventricular outflow
tract
⦁ At the level of the base can show the movement of the
mitral valve leaflets in short-axis
⦁ At the level of mid-LV can show papillary muscles

30. Apical four chamber (A4C)
⦁ This view is obtained at the apex of the heart and
looking toward the base of the heart (where the
valves are).
⦁ In this view, the mitral valve, tricuspid valve, and all
four chambers are visible.
⦁ This view shows the right ventricle from base to apex
and is a useful view to estimate RV systolic function

31. A4C

32. Structures visible:
⦁ Inferior septum and anterior lateral segments of the
left ventricle
⦁ Right ventricle
⦁ Left atrium
⦁ Right atrium
⦁ Mitral valve
⦁ Tricuspid valve

33.  Measurements in this view can be used to quantify
the heart:
⦁ RV size and function
⦁ Left atrial size
⦁ Right atrial size
⦁ Mitral valve flow is best seen in this view and has the
best angle with probe to estimate flows
⦁ Tricuspid valve flow
⦁ Tissue doppler at the mitral valve annulus (septum &
lateral wall) for diastolic function
⦁ Agitated saline bubble study for right to left shunting
(PFO, ASD, VSD)
⦁ With contrast, apical and mural LV thrombi can be
easily seen

34. Apical three chamber (A3C)
⦁ This view is obtained at the same window as the
apical four chamber and then rotation of the probe.
⦁ In this view, the mitral valve and aortic valve are in
view and is roughly similar to the parasternal long
axis.
⦁ In this view, the LV outflow tract is best in alignment
with the probe and so gives the best estimate of flow
through the LVOT, which is commonly used to
estimate aortic stenosis.

35. A3 CHAMBER

36. ⦁ Structures visible:
Aortic valve
Mitral valve
Left ventricle
Left atrium
⦁ Measurements in this view can be used to
quantify the heart:
Left ventricle outflow tract volume-time integral
(LVOT VTI) used in conjunction with aortic valve VTI
for aortic valve area and stenosis
Mitral valve flow

37. Apical two chamber (A2C)
⦁ This view is obtained at the same window as the
apical four chamber and then rotation of the probe.
In this view, the mitral valve is visible with the left
atrium and left ventricle.
⦁ Structures visible:
Anterior and inferior segments of the left ventricle
Mitral valve in long-axis
Left atrium
⦁ Measurements in this view can be used to
quantify the heart:
Mitral valve flow
Spectral doppler of the mitral valve

38. A2C

39. Subcostal
⦁ This view is obtained below the sternum and at the
top part of the abdomen.
⦁ In this view, the junction of the inferior vena cava
with the right atrium is best seen.
⦁ From this window, it is possible in some people to
see roughly equivalent views of the apical four
chamber and parasternal short views.
⦁ In some people, this may afford these common
views but at a subcostal window that may not be
obtained through the parasternal and/or apical
windows because of various reasons such as chest
wall trauma, open wounds, or poor acoustic windows

40. 🞂 . However, the subcostal window is the only window
to view the inferior vena cava that can help support
an estimation of the central venous pressure based
on size and collapsibility during respiration.
⦁ Other non-cardiac structures are visible in this view
and some pathologies — such as ascites — can be
observed.

41. Subcostal

42. Suprasternal (SSN)
⦁ This view is obtained above the sternum in the
suprasternal notch.
⦁ In this view, the aortic arch and portion of the
descending aorta can be seen. Color and spectral
doppler through the descending aorta can show
signs of coarctation of the aorta.

44. USE S OF ECHO
HELPS IN IDENTIFICATION OF:
⦁ Blood clots in the heart
⦁ Fluid in the sac around the heart
⦁ Problems with the aorta, which is the main artery
connected to the heart
⦁ Cardiomyopathy : dilated, restrictive, and hypertrophic
⦁ Pulmonary hypertension (requires some degree of
tricuspid regurgitation)
⦁ Septal defects including ASD & VSD
⦁ Stenosis and regurgitation/insufficiency of valves

45. ⦁ Structure and function of prosthetic valves
⦁ Thoracic ascending aortic aneurysm
⦁ Infiltrative diseases such as amyloidosis
⦁ Cardiac tamponade (it can suggest subclinical
diagnosis)
⦁ Evaluation of congenital diseases (eg: Tetralogy of
Fallot, transposition)
⦁ Pulmonary embolism
⦁ Endocarditis (sensitivity is higher with TEE)

46. Cardiac amyloidosis
⦁ Cardiac amyloidosis is a disorder caused by
deposits of an abnormal protein (amyloid) in the
heart tissue. These deposits make it hard for the
heart to work properly.

48. CARDIAC TAMPONADE
⦁ In this condition there is right venticular or atrial
compression that is accompanied with the opening
or closure of valves.

50. DIALATED CARDIOMYOPATHY
⦁ The ventricles are dilated more than the normal.

51. HYPERTROPHIC CARDIOMYOPATHY
⦁ The intra ventricular septum appears thickened

52. RESTRICTIVE CARDIOMYOPATHY
⦁ The ventricles are smaller when compared to the
atrium

53. LEFT VENTRICULAR HYPERTROPHY

54. MITRAL VALVE PROLAPSE

55. PAPILLARY MUSCLE RUPTURE

56. INFECTIVE ENDOCARDITIS