BASIC
ECHOCARDIOGRAPHY
BY:
DEEPAK GHIMIRE
MEDICAL INTERN
SOUTHWESTERN UNIVERSITY
SCHOOL OF MEDICINE
PRESENTED OCTOBER ,2015
PERCEPTOR INCHARGE: VICENTE G. BALBUENA,MD
ECHOCARDIOGRAPHY
Cardiac Anatomy
Base
Apex
Circulation through the Heart
The Cardiac cycle
4 phases of Diastole
Isovolemic relaxation
2. Rapid ventricular filling
3. Slow ventricular filling
4. Atrial contraction
1.
4 phases of Systole
Isovolemic contraction
2. Rapid ventricular ejection
3. Slow ventricular ejection
1.
The Cardiac cycle
DIMENSIONS & MEASUREMENT
Internal diameter
LV : <5 cm
RV : 2.2 4.0 cm
RA: 3.5 4.0 4cm
Internal diameter :
LA, RA & Ao root : < 4cm
Imaging Modalities
1. 2D- Echocardiography
2. M-mode Echocardiography
Echocardiography
A non-invasive diagnostic technique
Widely used in clinical cardiology.
Involves the use of ultrasound
Used to assess cardiac structure and
hemodynamic function function.
Fig. Echocardiography machine
Indications of 2D Echocardiography
May be divided into structural imaging and
hemodynamic imaging (*ASE)
Indication for Structural imaging
Pericardial imaging (P. Effusion)
L/R ventricles & cavities (RVH/LVH or wall motion abnormality or
thrombi)
Image of valves ( Stenosis or prolapse)
Great vessels (aortic dissections)
Congenital & Traumatic heart diseases
Hypertension, suspected IHD, murmurs, Pulmonary disease
Arrythmias, palpitations, syncope or Neurological disease
Indications of 2D Echocardiography
May be divided into structural imaging and
hemodynamic imaging (*ASE)
Indication for hemodynamic imaging
through Doppler techniques:
Blood flow through heart valves (stenosis/ regurgitation)
Blood flow through the cardiac chambers (C.O)
Systolic and diastolic functions
Pocket-sized Echocardiography Machine
Echocardiography
Physics :
Makes use of Ultrasound ( sound >20 Khz frequency)
Usual frequency used : 1 5 Mhz
Measures two quantities
1. Time Delay between transmission of pulse and
reception of echo
2. Intensity of reflected echo
Principle of Image generation
Gray Scale Image
Gray scale Image is
generated Based on
intensity of reflected echo
Black
Fluid or blood
White
Calcifications on cardiac
valves/ pericardium
Gray
Myocardium
Fig: Pericardial effusion
Factors in Echocardiography
Transducers
Use of lens in tranducer
Image Quality
Fig: Image generated by
3 Mhz tranducer
Fig: Image generated by
5 Mhz tranducer
Modes of Display
M-Mode echocardiography
MOTION-MODE (M-MODE) ECHO
Better display of :
Motion and thickness of ventricular walls
Changing size of cardiac chamber
Opening and closure of valves is better
Echocardiography provided information about
Structure of heart and great vessels
Doppler imaging provides information about
the function, physiology and hemodynamics
Echo vs. Doppler studies
Pulse
Continuous
Phased array transducer
The typical frequency range: 1-5 MHz
Has an orientation marker
Corresponds with the Image
Transthoracic Acoustic Window
Trans-Thoracic Echo (TTE)
1.
2.
3.
Parasternal view
Apical view
Subcostal view
Trans-Esophageal Echo (TEE)
Assess posterior cardiac
structures
Parasternal Long Axis View (PLAX)
* marker orientated towards the right clavicle (approximately 11 oclock)
Parasternal Long Axis View (PLAX)
Structure
Assessment
RV (right
ventricle)
Size and function
LV (left
ventricle)
Size and function
(septum)
Ao (ascending
aorta)
Size
AV (aortic
valve)
Motion, opening
and calcification
MV (mitral
valve)
Motion, opening
and calcification
Pericardium
Fluids
Assessment :
1. Pericardial space
2. RV
3. Septum
4. LV
5. Anterior MV leaflet
6. Aortic root
7. LA
Parasternal Long Axis View (PLAX)
Parasternal Long Axis View (PLAX)
Fig. Calcification of mitral annulus
Pericardial effusion
Parasternal short-axis view (PSAX)
* PLAXS rotate clockwise 90 degrees (
to long axis of LV)
PLAX & PSAX
PSAX
The probe can be tilted to examine the
SAX view at different levels:
1. Level of papillary muscles
2. Mitral valve
3. Level of aortic valve
PSAX
Apical Four Chamber View (A4C)
* marker is at around 3 oclock.
Apical Four Chamber View (A4C)
Assessment :
1. Pericardial space
2. LV
3. Septum
4. RV
5. RA
6. Interartrial septum
7. LA
[Link] annulus
Apical Four Chamber View (A4C)
Apical Five Chamber View
Apical view
Apical Two Chamber View (A2C)
45 to 90 degrees anticlockwise rotation of transducer
probe marker from apical view to to 12 oclock.
Visualizes the true anterior and true inferior walls of the
LV
Apical Two Chamber View (A2C)
Subcostal Long Axis View
* Transducer in Right sub xiphiod area & side marker in 3 oclock position
Subcostal Long Axis View
Assessment :
1. Pericardial space
2. RV
3. Septum
4. MV annulus
5. LV
6. IVC
Trans-Esophageal Echocardiography
Used to assess
posterior
structures like
LA or Aorta
Contrast echocardiography
Before and after contrast
Indications of 2d Echocardiography in
evaluation of Heart murmurs
PLAX
MR, AR , VDS
Subcostal :
PSAX (multiple level)
AR, TR, PS, PR, VSD
Apical :
4chamber : MR, TR
2 chamber: MR
Long axis: MR, AR, AS,
LVOT
5 chamber: LV outflow,
AR, AS
4chamber- RV inflow, TR,
ASD
Short axis (Basal) TR, PS,
PR
Mid venticular: IVC, HV
Suprasteral:
Aortic arch, Aortic flow
Right Parasternal Lx
Ascending aorta, AS
Two-Dimensional Echocardiography
Cardiac chambers
Chamber size
Left ventricular
Hypertrophy
Regional wall motion
abnormalities
Valve
Morphology and motion
Pericardium
Effusion
Tamponade
Masses
Great vessels
Transesophageal
Echocardiography
Inadequate transthoracic
images
Aortic disease
Infective endocarditis
Source of embolism
Valve prosthesis
Intraoperative
2D Echocardiography
An ideal imaging modality for assessing left
ventricular (LV) size and function.
The gold standard for imaging valve morphology
and motion
The imaging modality of choice for the detection of
pericardial effusion
The definitive diagnosis of a suspected aortic
dissection usually requires a TEE.
DOPPLER ECHOCARDIOGRAPHY
Uses ultrasound reflecting off moving RBC to
measure the velocity of blood flow across valves,
within cardiac chambers, and through the great
vessels.
Normal and abnormal blood flow patterns can be
assessed noninvasively.
DOPPLER ECHOCARDIOGRAPHY
The different colors indicate the direction of blood flow:
Red toward the transducer
Blue away from the transducer
Green superimposed when there is turbulent flow.
Blue Away Red Towards (BART)
DOPPLER ECHOCARDIOGRAPHY
Valve gradients in stenosis ( Inc. velocity )
Valvular regurgitation (retrograde flow)
Intracardiac pressures (PAH)
Cardiac output (area X velocity)
Diastolic filling
Congenital heart disease (shunts)
VSD
Aortic Regurgitation
Fig: TEE: Dilated ascending aorta
Fig. TEE: Aortic Regurgitation
Other use of Echo
Hypovolemia
kissing LV
chambers
Collapsing IVC
Temponade
Cardiac Temponade
IVC dilation
Diastolic RV collapse.
Cardiac masses and Tumors
Pleural Effusion
Echocardiography
The quality of an echo is highly operator
dependent and proportional to experience and
skill.
The value of information derived depends heavily
on operation and interpretation
Sources and Assistance
Harrison Principle of Internal medicine, 19th ed
Harrison Principle of Internal medicine, 18th ed
Fiegenbaum's Echocardiography 6th edition
Introduction to Transthoracic echocardiography
Stanford University School of Medicine
Radiology staff of SHH, SWU
Good Morning !
