ECHO

MADE EASY

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 CD CONTENT

• Procedure on how to perform an Echo?

 ECHO
MADE EASY
Second Edition

Atul Luthra
MBBS MD DNB
Diplomate
National Board of Medicine
Consultant
Physician and Cardiologist
New Delhi

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Echo Made Easy

© 2007, Atul Luthra

All rights reserved. No part of this publication and Interactive CD ROM should be reproduced, stored in
a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original. Every
effort is made to ensure accuracy of material, but the publisher, printer and author will not be held
responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled
under Delhi jurisdiction only.

First Edition : 2005

Second Edition : 2007

ISBN 81-8448-084-9

Typeset at JPBMP typesetting unit

Printed at Ajanta Press
 To
My Father
Mr PP Luthra
who made me
&
to
My Mother
Ms Prem Luthra
whose fond memories
always guide me
 PREFACE TO THE SECOND EDITION

As I write this preface to the second edition of Echo Made Easy,

my thoughts go back to the time when I was skeptical about
authoring this book. My concerns were whether there was a
genuine need for it and whether I was the right person to write it.
But thanks to my readers for their appreciation, my publishers
for their support and my father for his encouragement, it gives
me immense pleasure to pen down the introduction to this
vastly improved version of Echo Made Easy.
First attempts are seldom the best as there is always a
scope for improvement. This was aptly pointed out by my critics
and colleagues. Therefore, the text has been changed into a
bullet-point format to improve readability and recall. The
illustrations and figures have been redrawn by my expert artist
and do appear strikingly more impressive. Colour-flow maps
have now been depicted in true colours, as they appear on the
screen during echocardiography. These are bound to leave a
lasting impression on the reader’s mind.
Colour-Doppler Echo, a recent advancement in echo-
technique, did not get its due importance in the earlier edition.
An entire new chapter has therefore been incorporated on
this intriguing subject, adequately supported by coloured illus-
trations.
I sincerely hope to continue to receive my share of bouquets
and brickbats because only they can spur me on to improve
even further. Do keep pouring in your comments and criticisms
and wish you a pleasant journey through this unique book.

Atul Luthra
atulluthra@sify.com
 PREFACE TO THE FIRST EDITION

Ultrasound has revolutionized clinical practice by providing the

fifth dimension to physical examination after inspection,
palpation, percussion and auscultation. Echocardiography is
the application of ultrasound for examining the heart. It is a
practically useful, widely available, cost-effective and non-
invasive diagnostic tool. Usage of echo is rapidly expanding
with more and more clinicians requesting for and interpreting it
to solve vexing clinical dilemmas.
While I was preparing the manuscript of this book, many a
time two questions crossed my mind. First, Is such a book
really required? And second, —Am I the right person to write it?
At the end of the day, I somehow managed to convince myself
that a precise and practical account of echocardiography is
indeed required and that an academic physician like myself
can do justice to this highly technical subject.
The book begins with the basic principles of ultrasound and
Doppler and the clinical applications of various echo-modalities
including 2-D echo, M-mode scan, Doppler echo and colour-
flow mapping. This is followed by an account of different echo-
windows and normal echo-views along with normal values and
dimensions. The echo features of various forms of heart
disease such as congenital, valvular, coronary and hypertensive
disorders are individually discussed. Due emphasis has been
laid on pitfalls in diagnosis, differentiation between seemingly
similar findings, their causation and their clinical relevance.
Understandably, figures and diagrams can never create the
impact of dynamic echo display on the video-screen. Neverthe-
less, they have been specially created to leave a long-lasting
visual impression on the mind. In keeping with the spirit of
simplicity, difficult topics like complex congenital cardiac
x Echo Made Easy
disease, prosthetic heart valves and transoesophageal
echocardiography have been purposely excluded.
This book is particularly meant for students of cardiology as
well as keen established clinicians wanting to know more about
echo. If I can coax some physicians like myself to integrate
echocardiography into their day-to-day clinical practice, I will
feel genuinely elated for a mission successfully accomplished.

Atul Luthra
 ACKNOWLEDGEMENTS

I am extremely grateful to:

• My school teachers who helped me to acquire command
over spoken and written English language.
• My professors at medical college who taught me the science
and art of clinical medicine.
• My heart patients whose echocardiograms stimulated my
grey matter and made me wiser.
• Authors of books on echocardiography to which I referred
liberally while writing the manuscript.
• M/s Jaypee Brothers Medical Publishers (P) Ltd who felt
confident to assign this project to me and provided expert
editorial assistance at all stages.
• My wife Arti and daughters Ankita and Aastha who left me to
myself while preparing and finalizing the manuscript of the
book.
• My readers who appreciated the first edition of the book and
encouraged me to improve it further.
 CONTENTS

1. What is an Echo? 1
• Principle of Ultrasound 2
• Principle of Doppler 6

2. Conventional Echo 13
• Two-dimensional (2-D) Echo 14
• Motion-mode (M-Mode) Echo 15
• Continuous Wave (CW) Doppler 16
• Pulsed Wave (PW) Doppler 18
• Clinical Applications of Conventional Echo 19

3. Colour Doppler Echo 21

• Principle 22
• Technique 24
• Advantages 25
• Limitations 26
• Applications 27

4. The Echo Windows 31

• Transthoracic Echo 32
• Echo Windows 33
• Transoesophageal Echo 41
• Future Directions in Echo 43
xiv Echo Made Easy
5. Normal Views and Values 45
• Normal Echo 46
• Sequence of Scanning 46
• What is Normal? 47
• Normal Variants 48
• Normal Values 49
• Normal Valves 55

6. Ventricular Dysfunction 61
• LV Systolic Dysfunction 62
• LV Diastolic Dysfunction 73
• RV Dysfunction 79

7. Cardiomyopathies 83
• Dilated Cardiomyopathy (DCMP) 84
• Restrictive Cardiomyopathy (RCMP) 89
• Hypertrophic Cardiomyopathy (HOCM) 92

8. Coronary Artery Diseases 99

• Indications for Echo in Coronary Artery 100
Diseases
• Myocardial Ischemia 101
• Myocardial Infarction 101
• Left Ventricular Dysfunction 106
• Right Ventricular Dysfunction 108
• Acute Mitral Regurgitation 109
• Acute Ventricular Septal Defect 111
 Contents xv
• Left Ventricular Aneurysm 112
• Ventricular Mural Thrombus 113
• Acute Pericardial Effusion 114
• Coronary Artery Anomalies 114
• Simulating Conditions 115
• Stress Echocardiography 115

9. Systemic Hypertension 119

10. Pulmonary Hypertension 125

11. Aortic Diseases 135

12. Congenital Heart Diseases 147

• Ventricular Septal Defect 148
• Atrial Septal Defect 151
• Patent Ductus Arteriosus 154
• Tetralogy of Fallot 156
• Eisenmenger Reaction 158
• Quantification of Shunt 159

13. Valvular Diseases 161

• Mitral Stenosis 162
• Mitral Valve Prolapse 172
• Flail Mitral Leaflet 175
• Mitral Annular Calcification 177
• Mitral Regurgitation 179
• Tricuspid Stenosis 186
• Tricuspid Regurgitation 189
• Ebstein’s Anomaly 195
xvi Echo Made Easy
• Aortic Stenosis 197
• Aortic Regurgitation 209
• Pulmonary Stenosis 219
• Pulmonary Regurgitation 222

14. Pericardial Diseases 227

• Pericardial Effusion 228
• Cardiac Tamponade 232
• Constrictive Pericarditis 234

15. Endocardial Diseases 237

16. Intracardiac Masses 247

• Cardiac Tumours 248
• Left Atrial Myxoma 249
• Cardiac Thrombi 253
• Ventricular Thrombus 256

17. Thromboembolic Diseases 259

18. Systemic Diseases 263

Index 267