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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
8.MV 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 !