Basic Echocardiography

Selwyn Wong Middlemore Hospital

Echocardiography Basics
Ultrasound waves sent from chest wall

Echocardiography Basics Two-dimensional imaging

Echocardiography Basics

Echocardiography Basics

Echocardiography Basics

Echocardiography Basics One-dimensional imaging (M-mode)

Echocardiography Basics One-dimensional imaging (M-mode)

Echocardiography Basics Doppler - Spectral Pulse Continuous

Bernoulli equation P = 4V2

Echocardiography Basics Doppler - Colour

Echocardiography Basics Tissue velocity imaging

Echocardiography Basics Tissue velocity imaging

Left ventricle - size Normal

End-diastole 3.5-5.7cm
End-systole 2.1-4.0cm

Left ventricle - size Normal

End-diastole 3.5-5.7cm
End-systole 2.1-4.0cm

Left ventricle - wall thickness

IVS and PW 0.6 -1.1cm

Left ventricle - systolic function Fractional Shortening (FS)

FS = EDD-ESD / EDD

Left ventricle - systolic function Fractional Shortening (FS)

FS = EDD-ESD / EDD

Left ventricle - systolic function

Left ventricle - systolic function

Ejection fraction (%)

Normal
Mild

>55
40-50

Moderate
Moderate-severe

30-40
20-30

Severe

<20

Part One
A 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily. On examination she has a pulse rate of 80/minute, blood pressure of 125/70 mmHg and a jugular venous pressure (JVP) of +1 cm. She has a soft systolic murmur with no added sounds, her chest is clear and she has no oedema. An ECG shows sinus rhythm. A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15.5/28 but no pulmonary congestion. Echocardiography demonstrates systolic dysfunction with fractional shortening of 18% and mild mitral regurgitation. Her serum creatinine level is normal.
Which of the following is the most appropriate next step in treatment? A. Increase the frusemide dose. B. Add digoxin. C. Add an aldosterone antagonist. D. Add an angiotensin II receptor antagonist. E. Add a beta blocker.

Left ventricle - diastolic function

Mitral inflow

Pulmonary veins

Mitral TVI

LV diastolic function - mitral inflow

E/A > 1

E/A < 1

E/A >>1

LV diastolic function - mitral TVI

E/A > 1

E/A < 1

E/A >>1

Left ventricle - RWMAs

Left ventricle - RWMAs

Left ventricle - RWMAs

Left ventricle - thrombus

Left atrium - size

Diameter Normal 2.0-4.0cm Mild 4.0-5.0cm Moderate 5.0-6.0cm Severe >6.0cm

Left atrium - size

Area Normal <20cm2 Mild 20-30cm2 Moderate 30-40cm2 Severe >40cm2

Left atrium - thrombus

Cardiac Valves Morphology

Valve dysfunction
aetiology

quantification
consequences

serial evaluation

Valve regurgitation - quantification

Colour - jet size/width
PISA Spectral doppler

Consequences

AR - LV Response
Chronic AR - decompensated LV

LVEF<55%, LVESD>55mm, LVESV 60ml/m2

Part One
A patient with aortic regurgitation has the following haemodynamic measurements: cardiac output (CO) 7.5 L/minute heart rate (HR) 75/minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat.

The regurgitant fraction in this patient is: A. 25%. B. 33%. C. 50%. D. 67%. E. 75%.

Part One
A 45-year-old asymptomatic man returns for follow-up. He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve. He has never had endocarditis. Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement?
LVEDD (mm)[35-55] A. B. C. D. E. Key: 70 75 70 65 75 FS [0.30-0.40] 0.30 0.40 0.25 0.45 0.35 LA size (mm) [<40] 60 40 45 50 55

LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) / LVEDD LA Left atrial

MR- Quantification of LV contractility

LV systolic function - most important parameter

Ejection fraction, fractional shortening, velocity of

circumferential fibre shortening - load dependent MR allows supranormal values of EF etc. Early systolic dysfunction if; EF < 60% (severe MR) ES diameter < 45mm (26mm/m2)

Mitral stenosis - quantification

Severity Mild Moderate Severe Very Severe MVA (cm2) >2.0 1.1-2.0 <1.0 <0.8 LAP (mm Hg) <10-12 ~10-17 >18 >20-25 CO NL NL

Part One
A 35-year-old woman has increasing breathlessness on exertion. Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm. The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following? A. Severe pulmonary hypertension (cor pulmonale). B. Aortic stenosis. C. Mitral regurgitation. D. Mitral stenosis. E. Aortic regurgitation.

Part One
A 28-year-old woman, who emigrated from Cambodia 10 years ago, presents to the emergency department with a three-week history of increasing shortness of breath, orthopnoea, nocturnal dyspnoea and ankle oedema. She is 25 weeks pregnant and has no significant past medical history. The presence of pulmonary oedema is confirmed clinically and radiologically. She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120/minute in sinus rhythm. Her blood pressure is 125/85 mmHg. Echocardiography demonstrates mitral stenosis with an estimated valve area of 1.3 cm2 and a left atrial diameter of 50 mm [<40 mm]. There are no other abnormalities. What is the most appropriate next step in management? A. Balloon valvotomy. B. Surgical valvotomy. C. Digoxin therapy. D. Beta-blocker therapy. E. Angiotensin converting enzyme (ACE) inhibitor therapy.

Part One
A 55-year-old man presents with acute pulmonary oedema. Five years earlier, he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St. Jude) for mixed mitral valve disease. He has been well with normal exercise tolerance prior to the day of admission. Examination on admission reveals tachypnoea, sinus tachycardia of 110/minute, blood pressure of 105/60 mmHg, elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields. His prothrombin timeinternational normalised ratio (PT-INR) is 1.9 [desired therapeutic range 2.0-3.5]. Serum urea, creatinine and electrolytes are normal. The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed. Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metres/second). What is the most appropriate course of action? A. Administration of intravenous streptokinase. B. Administration of intravenous heparin. C. Administration of intravenous antibiotics. D. Addition of an antiplatelet agent. E. Immediate mitral valve replacement. .

Aortic stenosis - quantification

Aortic stenosis - quantification

Mean gradient (mmHg) Peak Ao velocity AVA (cm2)

Normal Mild Moderate Severe <20 20-40 >40

1.0-2.0 2.5-2.9 3.0-4.0 >4.0

>2.5 >1.7 1.0-1.7 <1.0

Right ventricle - size & function

Estimation of Pulmonary Pressure PA systolic pressure

Tricuspid regurgitation jet velocity

Estimation of Pulmonary Pressure RA pressure

IVC size

Part One
The severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation. This method uses the Bernoulli equation which states that P = 4v2 (where P = instantaneous pressure gradient and v = velocity across the valve). There is tricuspid regurgitation with a peak velocity of 4 metres/second and a mean velocity of 3.5 metres/second. Assuming right atrial pressure is 5 mmHg, the best estimate of the peak right ventricular systolic pressure ( 2 mmHg) is:

A. 50 mmHg. B. 55 mmHg. C. 60 mmHg. D. 65 mmHg. E. 70 mmHg.

Cardiac Tamponade

Cardiac Tamponade

Cardiac Tamponade

Part One
A 65-year-old woman presents with a one-week history of progressive dyspnoea. On admission, there are signs of shock, a systolic murmur and an elevated jugular venous pressure. The ECG shows sinus tachycardia but no other abnormality. An antero-posterior chest X-ray shows cardiomegaly. The serum troponin I level is 0.5 mg/L [<0.1]. A computed tomography (CT) scan is shown below.
What is the most likely diagnosis? A. Pulmonary embolism. B. Right ventricular infarction. C. Pericardial tamponade. D. Myocarditis. E. Acute mitral regurgitation.

Endocarditis

Positive echocardiogram for IE

Discrete, echogenic, oscillating intracardiac mass located at a site of endocardial injury (e.g., on a valve or supporting structure, in pathway of regurgitant jet, or site of implanted material), or Periannular abscess, or New dehiscence of a prosthetic valve

Cardiac Resynchronisation

Cardiac Resynchronisation
Severe heart failure treatment to restore coordination to LV contraction NYHA 3-4 EF < 35% QRS duration > 120 msec

Echocardiography

Useful non-invasive tool

Reports objective and subjective

Limitations