Echocardiography,

Dopplercardiography,
Physical principles,
Indications, Limitations,
Normal values, The reporting
format of Echo, Diastolic and
systolic dysfunction

What is an Echo?
Use of ultra sound to
examine the heart

What are types of

Echocardiography?
M mode echo
2 DIMENSIONAL ECHO:
Transthoracic Echo- transducer directly on the
chest wall
Transesophageal Echo- probe placed into the
esophagus and stomach
Stress echocardiography- Tran thoracic echo at
rest and post stress or exercise
Others: Contrast, 3-D, 4-D

What does an Echo do?

Chamber size,
thickness and function
Assess all cardiac
valves
Assess hemodynamics
Congenital heart
diseases
Some extracardiac
shunts

Who can perform it?

Obviously Echocardiologists as categorized
by ASE (American Society of
Echocardiography)
Cardiac Sonographers with proper and
formal training in the field

Advantages of Echocardiography
Non-invasive (TTE)
Accurate assessment of structural
abnormalities such as valvular dysfunction
and LVH
No ionizing radiation
Portable

Limitations of the Echo

Inability to obtain high quality pictures
especially with the transthoracic approach
Diagnostic accuracy is operator -dependent
Expensive may not be affordable for all.
Hi tech diagnostics

Ultrasound production
Sound is a disturbance propagating in a
material.
Each sound has a characteristic frequency
and intensity (Hz, KHz, MHz).
Sound higher than 20KHz is not perceived
by the human ear and is called ultra sound.
Velocity of sound in cardiac tissue
is1540m/s

Piezoelectric effect
Ultra sound results from the property of
certain crystals like barium titanate to
transform electrical oscillations into
mechanical oscillations.
The same crystals can also act as
ultrasound receivers (mechanical
electrical)
Ultrasound waves may be reflected, or
absorbed or refracted as they traverse
tissues

Physics and Instrumentation ctd.

I. Transducer containing Piezoelectric
Element Converts electrical to Ultrasound beam
(in millions of cycles per second)

II. When Directed towards the heart reflected

Ultrasound (echo) is converted back to
energy by the Piezoelectric
element which permits
Construction of an image using:

Intensity of Echoes (frequency)

efines density of different tissue
Interfaces in the heart

Time taken for echoes to arrive

Back to the transducer i.e. distanc
From the transducer

Indications for echocardiography

Suspected heart failure or at high risk of
developing it, who have not yet had an echo
scan
Screening of those with established ischaemic
heart disease, i.e. a past history of:
myocardial infarction,
atrial fibrillation or
re-vascularisation, who have not had and echo
scan

 Murmurs of unknown cause

Investigation of shortness of breath who
have an abnormal ECG
Screening relatives of patients with
cardiomyopathies
Symptoms and signs related to cardiac
etiology e.g. DIB on exertion, murmur.
Initial evaluation of known or suspected
heart failure and re-evaluation if there is a
change in clinical status

 Routine evaluation of patients with valvular

stenoses or regurgitation.
Evaluating valvular heart disease.
evaluation of suspected infective
endocarditis.
Prior testing suggesting heart disease; such
as a CXR with cardiomegaly, an elevation of
BNP- a marker of heart failure

 Known or suspected adult congenital

disease.
Sustained supraventricular and ventricular
tachycardia.
Evaluation of myocardial ischemia /
infarction
Evaluation of complications of myocardial
ischemia/ infarction; reduced ejection
fraction, shock etc

 For evaluation of suspected or known

pulmonary hypertension; right ventricular
function and estimation of pulmonary artery
pressure
Evaluation of suspected cardomyopathygenetic restrictive or infiltrative and
screening for inherited cardiomyopathy in
first degree relatives of patients with
inherited cardiomyopathy

 Baseline and serial evaluations in patients

undergoing chemotherapy
Evaluation of cardiac structure and
chambers for source of embolus. Neoplasm
or cardiac thrombus
Evaluation of pericardial disease e.g.
pericardial effusion or constrictive
pericarditis.

 Evaluation of aortic disease e.g syphilitic

aortitis or marfans syndrome
Initial evaluation of suspected hypertensive
heart disease

Patient preparation
Give a brief and simple
explanation to patient
Patient should be striped
to the waist and asked to
lie flat on the couch.
Female patients could
wear a gown which opens
to the front.
ECG leads should be
attached to the patient
Time cardiac events
Observe the heart rate

Echo windows

Echo planes

Echo views

Parasternal veiws
Long and Short axes
Apical views
4 Chamber view
5 Chamber view
Long axis (2 Chamber)
Subcostal views
Long and short axes
Suprasternal views
Long and short axes

Parasternal Long Axis

The parasternal exam

Transducer in the 3rd or 4th intercostal space

Long axis view of the left ventricle

Transducer groove facing the right shoulder

Visualise;
Long axis of the LV and LVOT.
Motion of LV anteroseptal and posterolateral wall
( recognize any hypokinesis, akinesis or
dyskinesis )
Aortic root and aortic valve leaflets.
LA cavity
MV; anterior and posterior leaflets, chordal and
papillary muscle attachments

 Measure;
LV dimensions in end-diastole: interventricular
septum, cavity, posterior wall
Aortic root diameter
Atrial dimensions

With colour visualize:

Regurgitation of mitral and aortic valves

Estimate (eye-ball):
LV systolic function
RV systolic function

The short axis view;

Perpendicular to the long axis views
with groove facing the left shoulder. View
by inferior or superior angulation of the
probe;
The mitral valve level
The aortic valve level
The papillary muscle level
The apex level

Parasternal Short Axis Papillary

Muscle Level

Parasternal Short Axis Aortic

Valve Level

The apical position

Patient in the lateral decubitus position.

Apical four chamber
The transducer is placed at the apical impulse with the
notch facing up to display the left ventricle on the right.
Rotate until all four chambers are seen with the tricuspid
and mitral valve in full excursion.
View; atrial septum
Apply colour flow to TV, MV and assess for any
regurgitation
Measure LA volumes, LV volumes
Measure mitral inflow pulmonary vein mitral annular
velocities (tissue dopplers)
Measure TV velocities

Apical Four Chamber

 Apical two chamber;

Rotate the transducer clockwise to 60 degrees from the
apical four chamber view
anterior myocardial wall motion.
inferior myocardial wall motion.
Apical three chamber;
Rotate the transducer anti-clockwise to 60 degrees from
the apical four-chamber view (parasternal long axis
recorded from the axis) to analyse the anterior and inferior
myocardial wall motion.
View;
Aortic outflow
Inferolateral and anteroseptal wall motion.

Other apical chamber views

Apical 2 chamber view

Apical 2 chamber view

Subcostal views

Transducer in midline, perpendicular to long axis of the

left ventricle.
View the foreshortened four-chamber view.
Visualize the atria, atrial septum and do a colour Doppler
on the interatrial septum
Assess RV free wall.
Rotate transducer 90 degrees counter clockwise.
Record; series of short-axis views.
Transducer groove down towards patients' spine:
Liver parenchyma,
hepatic vessels
inferior venacava.

 Superior tilt; Drainage of hepatic vein into inferior

venacava.
Right rotation; Inferior venacava along its long axis
Color imaging and Doppler recording of the
hepatic vein identifies;
Severe TV regurgitation,
PHT.
Restrictive filling.
Further superior tilt; four chamber

Subcostal View

Sub-costal View, short axis

Sub-costal
Sub-costal
Short
Short axis
axis

Supra sternal view

Extend the patients neck
Place transducer in suprasternal notch, long axis of the
transducer to the left of the trachea. Transducer groove
directed to the right supraclavicular region.
View;Great vessels: Ascending aorta, aortic arch with
the origin of the brachiocephalic trunk, the left common
carotid artery, the left subclavian artery from before
laterally.
The right pulmonary artery inferior to the aortic arch
Rotate 90 degrees to view short axis of aortic arch with
the right pulmonary artery and the left atrium inferior to it.

Motion/ M- Mode
Produced by transmission and reception of
ultra sound signal along only one line.
Produces a graph of depth and strength of
reflection with time.
US signal should be aligned perpendiculary
to the structure being assessed
Complimentary mode used to measure size
and thickness of cardiac chambers.

Echocardiography Basics
One-dimensional imaging (M-mode)

CHAMBER MEASUREMENTS AND

ASSESSMENT OF SYSTOLIC
FUNCTION
Left ventricle
From the 2D long-axis view; at the level of the
mitral valve tips
At end diastole measure; septal wall, LV diastolic
diameter, LV posterior wall.
At end-systole measure; LV systolic diameter.
Calculate fractional shortening (LVDd-LVSd/LVDd)

Parasternal axis showing

measurement of internal diameter

 From M-mode (if there is no regional wall

abnormality),ensuring that the M-mode line
is perpendicular to the long axis of the LV.
Fractional shortening and ejection fraction
can be calculated from these data

Doppler Echocardiography
Determines the velocity and direction of blood flow by
measuring the change in frequency produced when
sound waves are reflected from red blood cells
The Doppler principle states- when a sound (or light)
signal strikes a moving object, the frequency of that
signal is altered, and the increase or decrease in
frequency is proportional to the velocity and direction at
which the object is moving
Doppler gives hemodynamic information regarding the
heart and blood vessels
Can be used to detect valvular leakage/regurgitations,
valvular narrowing, intracardiac shunts e. g VSDs,
ASDs

Basic principle of the Doppler shift. During diastole (left panel), an ultrasound beam directed toward the
junction of the mitral and aortic annuli is reflected by red blood cells moving toward the transducer. The
frequency of the received ultrasound is greater than that of the transmitted beam, and the spectral
tracing is recorded above the baseline (i.e., flow is toward the transducer). During the isovolumic phase
(middle panel), both the mitral and AoVs are closed and little flow occurs within the left ventricle.
Therefore, there are no significant changes in the transmitted and received frequencies of the Doppler
beam and no spectral tracing is recorded. During systole (right panel), the transmitted beam is reflected
by red blood cells moving away from the transducer. Therefore, the frequency of the received ultrasound
is lower than that of the transmitted beam, and the spectral tracing is recorded below the baseline.

doppler techniques
3 commonly used techniques
Continuous- Wave (CW) Doppler
Pulsed-Wave Doppler
Color-Flow Doppler
Continuous- Wave (CW) Doppler
Sound waves are both transmitted and received
continuously. There are two crystals in each transducer,
one for transmitting and one for receiving.
Because all flow velocities along the beam are recorded,
CW Doppler cannot define individual signals at specific
distances from the transducera problem referred to as
range ambiguity.
CW Doppler can accurately measure the direction and
velocity of overall flow but cannot discern the precise site
of origin of individual components within the signal

Pulsed wave doppler

Utilizes a single crystal to transmit a signal and then
receive after a preset time delay
Short bursts of signal are transmitted from the
transducer at a given pulse repetition frequency
(PRF).
Reflected signals are only recorded from a depth
corresponding to half the product of the time delay
and speed of sound in tissues(1540m/s)
Combining this with 2D imaging a small sample
volume can be identified on the screen showing the
region where velocities are being measured.
Because the time delay limits the rate at which
sampling can occur, there is a limit to the maximum
velocity that can be accurately detected .

Color-Flow Doppler (CFD)

Major limitations of PW and CW Doppler (spectral Doppler) is that no
spatial information regarding the size, shape, and 2D direction of flow is
provided.
In CFD, rapid pulsed-wave interrogations are performed at multiple sites
for multiple scan lines to create a spatially correct and dynamic display
of moving blood within the heart and vasculature.
Doppler signals are presented as colors assigned to individual sites

BART Convention and increasing velocity is depicted in brighter

shades of each color.
Areas of turbulence or regions of high flow acceleration are often
indicated in green
CFD also can be superimposed onto M-mode tracings , often termed
Color M-mode imaging, where is helpful in clarifying the timing of flow
phenomena.

Apical four-chamber images with color-flow Doppler during diastole and systole.
Red flow indicates movement toward the transducer (diastolic filling); blue flow
indicates movement away from the transducer (systolic ejection). LV, left
ventricle; RA, right atrium; RV, right ventricle

Normal Intracardiac Doppler Velocities

Right ventricle
Tricuspid flow 0.30.7 m/sec
Pulmonary artery 0.60.9 m/sec

Left ventricle
Mitral flow 0.61.3 m/sec
Aorta 1.01.7 m/sec

Transesophageal & Stress

Echo
Transesophageal Echo (TEE)
Transducer through oesophagus

evaluation images of posterior cardiac structures

(e.g. LA, LA appendage, interatrial septum, aorta
distal to the root),
Emphysema, Severe obesity, Chest wall deformity

delineation of cardiac structures <3 mm in size (e.g.

small vegetations or thrombi)
Prosthetic valves

Stress echocardiography

Wall motion defects

Difficult to get clear image
Pre operative assessment for angioplasty and CABG
False positive ECG

Transesophageal echocardiography

Normal Values
Parameter
Thickness of the (IVS)
Thickness of (LVPW)
LV Inner diameter (LVID)
LV end systolic diameter
(LVSD)
RV diameter (RV)
Diameter of Left Atrium (LA)
Diameter of Aortic Root (AO)
Aortic Cusp separation
Fractional Fibre shortening
(FS)
FS=EDD-ESD/EDD
100 LV Ejection Fraction (EF)
Est.

Normal
Range*cm)
0.6-1.1
0.6-1.1
3.5-5.7
2.5-4.5

Mean

0.9-2.6
1.7-4.0
2.0-3.7
1.5-2.6
25-45%

1.7
2.7
2.7
1.9
35

0.9
0.9
4.7
3.5

EF=EDD-ESD/EDD 100

40-75%

Reporting format
Summarised on a form with Date, Patient
Particulars( Name, sex, Indication for the
Echo).
Summary of the Measurements in tabular
form
Comment on the general shape size &
function of the L and R Atria, Ventricles.
Comment on the valvular function i.e., M,
T,A & P
Final impression given the observations.
The report may be accompanied by a VCD
or DVD recording of the actual echo.

References
Kasper, Braunward, et al, Harrisons
Princriples of Internal Medicine 17th
edition, 2005, McGraw Hill Publishers.
Echo Made Easy, by Sam Kaddoura
William Ganong, Review of Medical
Physiology, 22nd edition, 2005, Lange.
Joseph Kisslo et al Principles of Doppler
echocardiography and The Doppler
Examination