Echocardiogram Dr Emily Player

2D Echo Structural and functional test of the heart Uses Ultrasound Sound waves are sent from the probe/ transducer by piezoelectric crystals (£££) 1 The waves travel back at various speeds producing an image US can’t travel through air therefore aqueous gel required to transmit signal Each signal sent as a plane and many lines of information are sent back, therefore a real time image is gained 1 Size of crystal relates to frequency of transducer, therefore increased image quality increased cost US signal send across the plane, as it hits various structures waveforms are sent back to transducer the piezoelectric crystals receive the signal and converts it to an electrical signal for processing (proportional to distance from transducer) Multiple signals are sent within 1 second to have a high frame rate in order to record a real time moving structural image

Doppler Doppler Uses moving structures i.e. blood flow the time difference is known as doppler shift 1 An equation is applied to the doppler shift (Fr-Ft) providing velocities of blood flow Blood flow velocity = c (Fr – FT)/2 FT (cos θ) 1 Colour, PW and CW doppler BART Blue- away from transducer. Red- towards Difference in frequency from signal transmitted from probe then it is scattered as it hits moving blood cells and signal received back produces doppler shift.

Indications in ITU LV function Significant Valve abnormalities Tamponade/ effusion RV dilatation Volume status Thrombus, rupture, aneurysmal LV

Performing an Echo Before you Start Figure 1: Source 2 Position patient- USS does not travel through bone and air Monitor Cardiac cycle with ECG Left or Right sided echo Patient ID Aqueous Gel

The Echo Windows Parasternal Views C1 Figure 2: Source 3 Long Axis – pointer to R shoulder Short Axis- pointer to L shoulder Position probe approximately at V2 chest lead on ECG Remember rib spaces Apical Views C2 4 and 5 chambers- pointer to L axilla 2 and 3 chambers- rotate 90° Subcostal C3 Probe flat, pointer to L horizontal

Echo Windows Parasternal Long Axis [4] Parasternal Short Axis [5]

Echo Windows [6] http://echocardiographer.org/TTE.html

Echo Windows Apical 4 Chamber View [7] Apical 5 Chamber View [8]

Echo Windows Apical 2 Chamber View [9] Apical 3 Chamber View [10]

Echo Windows Subcostal [11], [12] Suprasternal [13]

Assessing the LV 3D Object M Mode Simpsons Method of Discs Global Impression Regional Wall Motion Abnormalities VTI, fractional shortening Tissue Doppler One of the more clinically useful methods for following left ventricular function is to evaluate the velocity time integral (VTI) of the left ventricular outflow tract or ascending aorta. The principle states that if the cross-sectional area of the chamber is known, then the product of that cross-sectional area and the mean flow velocity equates to the volumetric flow. As the heart is a pulsatile flow system, in which the flow velocity occurs during systole, the volume calculated equals the forward LV volume in the aorta. This forward stroke volume can then be multiplied by the heart rate to obtain the cardiac output (Figure 10).

LV Normal measurements [14], [15] Mild Mod Severe LV wall thickness IVSd / PWd (cm) 0.6–1.2 1.3–1.5 1.6–1.9 >2.0 LV dimension, women LVIDd (cm) 3.9–5.3 5.4–5.7 5.8–6.1 >6.2 LVIDd / BSA (cm/m2) 2.4–3.2 3.3–3.4 3.5–3.7 >3.8 LV dimension, men 4.2–5.9 6.0–6.3 6.4–6.8 6.9 2.2–3.1 3.2–3.4 3.5–3.6 3.7

Simpsons Method of Discs [14] LV function assessment using Simpson's method1 Parameter Formula Value (range) LV end-diastolic volume (LVEDV) ml/m2 49-85 LV end-systolic volume ml/m2 17-37 Stroke volume (SV) ml/m2 LVEDV-LVESV 26-54 Ejection fraction (EF) (%) SV/LVEDV 49-71

Regional Wall Abnormalities [14]

Video Links http://www.criticalecho.com/content/tutorial-5-assessment-lv-systolic-function http://www.bing.com/videos/search?q=echo+LV+function+regional+wall&FORM=HDRSC3#view=detail&mid=D9B34BADCC4C0BBF6ACBD9B34BADCC4C0BBF6ACB (apical wall) http://www.bing.com/videos/search?q=echo+LV+function+regional+wall&FORM=HDRSC3#view=detail&mid=025440278D623A9003C4025440278D623A9003C4 (lateral wall) http://www.bing.com/videos/search?q=echo+LV+function+regional+wall&FORM=HDRSC3#view=detail&mid=10ADDDEAA7F5D4E3AD6410ADDDEAA7F5D4E3AD64 (septal wall)

Right Ventricle [16] RV dimensions (apical 4 chamber) Abnormal Basal RV diameter (RVD1) (cm) >4.2 Mid RV diameter (RVD2) (cm) >3.5 Base to apex length (RVD3) (cm) >8.6

References 1.http://emedicine.medscape.com/article/1820912-technique#aw2aab6b4b1aa, accessed on 25.02.15 2. http://www.mayoclinic.org/tests-procedures/echocardiogram/multimedia/echocardiogram/img-20007334, accessed on 25.02.15 3.http://www.henryfordultrasounduniversity.com/wp-content/uploads/2010/06/pg26_EchocardiographicWindows2.jpg, accessed on 25.02.15 4. http://www.yale.edu/imaging/echo_atlas/views/, accessed on 25.02.15 5. http://www.finalfrca.co.uk/wp-content/uploads/2013/10/PLAX.gif, accessed on 25.02.15 6. https://afghanheart.files.wordpress.com/2013/09/short-axis-view-echo.jpg, accessed on 25.02.15 7. http://www.yale.edu/imaging/echo_atlas/views/four_chamber.html, accessed on 25.02.15 8. https://web.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/Apical_5_chamber_view, accessed on 25.02.15 9. http://www.yale.edu/imaging/echo_atlas/views/apical_2c.html, accessed on 25.02.15 10. http://webservice1.mvm.ed.ac.uk/imaging/demo/echo-section/basic_echo_3chamber.html, accessed on 25.02.15 11. http://www.ultrasoundcriticalcare.com/cardiac-subcostal-view/, accessed on 25.02.15 12. https://cardiophile.org/echocardiographic-profile-in-pulmonary-hypertension-2/, accessed on 25.02.15 13. http://echocardiographer.org/TTE.html, accessed on 25.02.15 14. http://www.bsecho.org/evaluation-of-systolic-function-of-the-left-ventricle/, accessed on 25.02.15 15. http://www.emergencyultrasound.org.uk/resources/05+LV+Function+web.pdf, accessed on 21.03.15 16. http://www.criticalecho.com/content/tutorial-5-assessment-lv-systolic-function, accessed on 21.03.15