introduction to echocardiography
TRANSCRIPT
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Presented ByBibini BabyII nd year MSc. Nsg Govt. College of NsgKottayam
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Echo
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Echo is something you experience all the time. If you shout into a well, the echo comes back a moment later. The echo occurs because some of the sound waves in your shout reflect off a surface (either the water at the bottom of the well or the wall on the far side) and travel back to your ears. A similar principle applies in cardiac ultrasound.
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History In 1842, Christian Johann Doppler (1803-1853) noted
that the pitch of a sound wave varied if the source of the sound was moving.
The ability to create ultrasonic waves came in 1880 with the discovery of piezoelectricity by Curie and Curie.
Dr. Helmut Hertz of Sweden in 1953 obtained a commercial ultrasonoscope, which was being used for nondestructive testing. He then collaborated with Dr. Inge Edler who was a practicing cardiologist in Lund, Sweden. The two of them began to use this commercial ultrasonoscope to examine the heart. This collaboration is commonly accepted as the beginning of clinical echocardiography as we know it today.3
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Generation Of An Ultrasound Image
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Echocardiography (echo or echocardiogram) 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.There is no special preparation for the test.
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Cont.
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Ultrasound gel is applied to the transducer to allow transmission of the sound waves from the transducer to the skinThe transducer transforms the echo (mechanical energy) into an electrical signal which is processed and displayed as an image on the screen. The conversion of sound to electrical energy is called the piezoelectric effect
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Machines
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There are 5 basic components of an ultrasound scanner that are required for generation, display and storage of an ultrasound image.
1. Pulse generator - applies high amplitude voltage to energize the crystals
2. Transducer - converts electrical energy to mechanical (ultrasound) energy and vice versa
3. Receiver - detects and amplifies weak signals 4. Display - displays ultrasound signals in a variety
of modes 5. Memory - stores video display
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Delivery RoutesTransthoracic window
Left parasternal Apical Subcostal Right parasternal Suprasternal Posterior thoracicTransesophagealIntravascular Intracardiac IntracoronaryEpicardial
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Transthoracic Echo
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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.The left arm is tucked under the head and the right arm lies along the right side of the bodyStandard positions on the chest wall are used for placement of the transducer called “echo windows”
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Parasternal Long-Axis View (PLAX)
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Transducer position: left sternal edge; 2nd – 4th intercostal spaceMarker dot direction: points towards right shoulderMost echo studies begin with this viewIt sets the stage for subsequent echo viewsMany structures seen from this view
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Parasternal Short Axis View (PSAX)
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Transducer position: left sternal edge; 2nd – 4th intercostal spaceMarker dot direction: points towards left shoulder(900 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.Many structures seen
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Papillary Muscle (PM)level
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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
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Apical 4-Chamber View (AP4CH)
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Transducer position: apex of heartMarker dot direction: points towards left shoulderThe AP5CH view is obtained from this view by slight anterior angulation of the transducer towards the chest wall. The LVOT can then be visualised
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Apical 2-Chamber View (AP2CH)
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Transducer position: apex of the heartMarker dot direction: points towards left side of neck (450 anticlockwise from AP4CH view)Good for assessment ofLV anterior wallLV inferior wall
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Sub–Costal 4 Chamber View(SC4CH)
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Transducer position: under the xiphisternumMarker dot position: points towards left shoulderThe subject lies supine with head slightly low (no pillow). With feet on the bed, the knees are slightly elevatedBetter images are obtained with the abdomen relaxed and during inspirationInteratrial septum, pericardial effusion, desc abdominal aorta
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Suprasternal View
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Transducer position: suprasternal notchMarker dot direction: points towards left jawThe subject lies supine with the neck hyperexrended. The head is rotated slightly towards the leftThe position of arms or legs and the phase of respiration have no bearing on this echo windowArch of aorta
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Systole/Diastole
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The Modalities of Echo
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The following modalities of echo are used clinically: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) DopplerColour flow(CF) Doppler
All modalities follow the same principle of ultrasoundDiffer in how reflected sound waves are collected and analysed
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Two-Dimensional Echo (2-D echo)
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This technique is used to "see" the actual structures and motion of the heart structures at work.
Ultrasound is transmitted along several scan lines(90-120), over a wide arc(about 900) and many times per second.
The combination of reflected ultrasound signals builds up an image on the display screen.
A 2-D echo view appears cone- shaped on the monitor.
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M-Mode echocardiography
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An M- mode echocardiogram is not a "picture" of the heart, but rather a diagram that shows how the positions of its structures change during the course of the cardiac cycle.
M-mode recordings permit measurement of cardiac dimensions and motion patterns.
Also facilitate analysis of time relationships with other physiological variables such as ECG, and heart sounds.
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Doppler echocardiography
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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 flowContinuous Wave (CW) useful for high velocity flow e.g aortic stenosis Color Flow (CF) 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.
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TEEclinical success of transesophageal
echocardiography First, the close proximity of the esophagus to the
posterior wall of the heart makes this approach ideal for examining several important structures. Second, the ability to position the transducer in the esophagus or stomach for extended periods provides an opportunity to monitor the heart over time, such as during cardiac surgery. Third, although more invasive than other forms of echocardiography, the technique has proven to be extremely safe and well tolerated so that it can be performed in critically ill patients and very small infants.
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TEEA form of upper endoscopyInformed consent should be obtained. The patient should fast for at least 4 to 6 hours Any history of dysphagia or other forms of
esophageal abnormalities should be sought. intravenous access and both supplemental
oxygen and suction should be available use topical anesthetic to numb the posterior
pharynx Airway can be inserted
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Procedure of TEEthe patient is placed in the left lateral
decubitus position. dentures, these should be removed, and in most patients, a bite block is placed between the teeth to prevent damage to the probe. After the probe has been lubricated with surgical jelly, it is introduced into the oropharynx and gradually advanced while the patient is urged to facilitate intubation. Once the probe has passed into the esophagus, a complete examination can usually be performed in 10 to 30 minutes.
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Epicardial Imaging
Application of an ultrasound probe directly to the cardiac structures provides a high-resolution, non obstructive view of cardiac structures. Because these probes are placed directly on the beating heart or vasculature, they must be either sterilized or more commonly placed in a sterile insulating sheath before use.
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Intracardiac Echocardiography
intracardiac (vs. intracoronary) echocardiography involves a single-plane, high-frequency transducer (typically 10 MHz) on the tip of a steerable intravascular catheter, typically 9 to 13 French in size.
Intravascular Ultrasound (IVUS) these are ultraminiaturized ultrasound transducers
mounted on modified intracoronary catheters. Both phased-array and mechanical rotational devices have been developed. These devices operate at frequencies of 10 to 30 MHz and provide circumferential 360-degree imaging.
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Contraindications to Transesophageal EchocardiographyEsophageal pathology
Severe dysphagia Esophageal stricture Esophageal diverticula Bleeding esophageal varices Esophageal cancer Cervical spine disordersSevere atlantoaxial joint disordersOrthopedic conditions that prevent neck flexion
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STRESS ECHO
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Stress echo is a family of examinations in which 2D echocardiographic monitoring is undertaken before , during & after cardiovascular stress
Cardiovascular stress exercise pharmacological
agents
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BASIC PRINCIPLES OF STRESS ECHO
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↑ Cardiac work load - ↑O2 demands- demand supply mismatch- ischemia
Impairment of myocardial thickening and endocardial motion
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Information obtained from Exercise Stress but not available with Pharmacological Test
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Exercise Duration/ToleranceReproducibility of Symptoms with ActivityHeart rate response to exerciseBlood Pressure response Detection of Stress Induced ArrhythmiasAssess control of angina with medical
therapyPrognosis
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Indication pharmacological stress echocardiography
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• Inadequate exercise• Left bundle branch block• Paced ventricular rhythm• pre-excitation or conduction abnormality• Medication: beta-blocker, calcium channel
blocker• Evaluation of patients very early after MI(<3
days) or angioplasty stent(<2weeks)• Poor image degradation with exercise• Poor patient motivation to exercise
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Pharmacologic Stress Agents
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Stress agents
Coronary vasodilator
DipyridamoleAdenosine
Inotropic agents
Dobutamine Arbutamine
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DOBUTAMINE STRESS ECHO
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Dobutamine- synthetic catecholamineInotropic & chronotropic- β1,β2 & α
Action: onset – 2 min half life – 2 min: continous IV
Metabolizd by cathechol-o-methyl transferase
Excretion: hepatobiliary system and kidney
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Dobut-protocol
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Protocol for Dobutamine Stress Echo.
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End points to terminate
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Myocardial contrast in stress echo
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Left vent opacification for border enhancement
Myocardial perfusion imaging
Perfusion at resting state-stress is performed and perfusion imaging is done at peak stress
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Stress EchoStress Echocardiography
Diagnosis Prognosis Viability
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INTERPRETATION OF STRESS ECHO
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Subjective assessment of regional wall motion
Compares wall thickening & endocardial excursion at baseline and stress
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INTERPRETATION OF STRESS ECHO
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Grade 1-normal 2-hypokinesis 3-akinesis 4-dyskinesis
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Hypokinesia-<5 mm of endocardial excursion
Akinesis - -ve syst thickening & endo excursion
Dyskinesis –systolic thinning & outward motion
normal response-hyperkinesis
Absence –low work load, β blockade, cardiomyopathy & delayed post stress imaging
Localisation>specific in multivessel dis & in LAD than RCA/LCX
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VIABILITY OF MYOCARDIUM
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That has the potential for functional recovery;-
either stunned/hibernating myocardium
>6mm thickness -viable segment
Stunned or hibernating improved contractility with dobutamine , not in infarcted myocardium
Biphasic response – low dose ↑contractility(10 to 20 mcg/kg), at higher dose CBF ↓-- contractility ↓
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Biphasic response is the most predictive of the functional recovery after revascularisation
Sustained improvement/no change-nonviable
For viability assessment – nuclear techniques are more
sensitive dobut stress echo more specific
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Contrast Echo
Contrast agents Intravenously injectedEnhance echogenicty of blood
Goal of contrast echoDelineation of endocardium by cavity
opacificationEnhance Doppler flow signalsImage perfusion of the myocardium
Increased sensitivityHeightened diagnostic confidenceImproved accuracy and reproducibilityEnhanced clinical utility
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Desired Contrast Agent Properties
Non-toxicIntravenously injectable (bolus or continuous)Stable during cardiac and pulmonary passageRemains within blood pool or has a well
specified tissue distributionDuration of effect comparable to duration of
echocardiography examinationSmall size
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Types of Contrast AgentsEncapsulated air bubbles (Albunex, Levovist)
1st generationHighly echogenic on left side (2 – 4 μm)Effective duration less than 2 minutes
Low solubility gas bubbles (Optison, Definity)2nd generationPerfluoropropane, perfluorocarbon, other gasesLonger duration
Agents with controlled acoustic properties3rd generation
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Microbubbles - Size
RBC6–8 µm
Microbubble2–8 µm
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Microspheres
AirHighly solubleLow persistence
and stabilityRapid diffusion
after disruption
Heavy GasesHigh molecular
weightLow solubilityHigh persistence
and stability
Villarraga et al. Tex Heart Inst J. 1996;23:90
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Contrast AgentsFDA approved
AlbunexOptisonDefinity
Approved outside USLevovistEchovist
Late clinical development
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Principle of Contrast EchoUltrasound-Contrast InteractionGas bubbles are
highly compliantBubbles in an
acoustic field resonate at the ultrasound frequency
Differentiating the contrast echo from ordinary tissue forms the basis contrast echo
Becher and Burns. Handbook of Contrast Echocardiography
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Principles of Contrast EchoHarmonic ImagingBubbles resonate at frequency of ultrasoundAt higher MI bubbles have non linear
oscillation and resonate at other frequencies with the “loudest” peak at double the ultrasound frequency (2nd harmonic)
Ultrasound machine can be set to only detect 2nd harmonic signals to improve resolution
Tissue also has harmonic properties
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Echo screeningLA/AO:LVEDD, LVESD,LVWI,EF:RWMA present/AbsentRWMA (specification)
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Alternatives to Contrast EchoTransesophageal echocardiographyMRINuclearAngiography Contrast echo is better…
Non invasiveWidely availableCan be done at bedside
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Conclusion
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Echocardiography provides a substantial amount of structural and functional information about the heart.Still frames provide anatomical detail.Dynamic images tell us about physiological functionThe quality of an echo is highly operator dependent and proportional to experience and skill, therefore the value of information derived depends heavily upon who has performed it
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