Gxymmm D History of Echocardiography Harvey Feigenbaum, M.D. Many histories of diagnostic ultrasound, and cardiac ul- trasound in particular, have been written." They all seem to address this field from a different perspective. One can begin the history in the twentieth century, Roman times, or any of the centuries in between. It is stated that a Ro- man architect, Vitruvius, first coined the word echo.” A Franciscan friar, Marin Mersenne (1588-1648), is fre- quently called the “father of acoustics” because he first measured the velocity of sound.’ Another early physicist, Robert Boyle (1627-1691), recognized that a medium was necessary for the propagation of sound.” Abbe Lazzaro Spallanzani (1727-1799) is frequently referred to as the “father of ultrasound,”* He demonstrated that bats were blind and in fact navigated by means of echo reflection us- ing inaudible sound. In 1842, Christian Johann Doppler (1803-1853) noted that the pitch of a sound wave varied if the source of the sound was moving.” He worked out the mathematical relationship between the pitch and the rel- ative motion of the source and the observer: The ability to create ultrasonic waves came in 1880 with the discovery of piezoelectricity by Curie and Curie."”"’ They noted that if certain crystalline materials are compressed, an electric charge is produced between the opposite surfaces. They then noted that the reverse was also true. If an electrical potential is applied to a crystal, it is compressed and de- compressed depending on the polarity of the electric charge, and thus very high frequency sound can be pro- duced. In 1912, a British engineer, L. F. Richardson, suggested that an echo technique could be used to de- tect underwater objects. Later during World War I, Paul Langevin was given the duty of detecting enemy sub- marines using sound, which culminated in the develop- ment of sonar.' Sokolov"? described a method for using re- flected sound to detect metal flaws in 1929, In 1942, Floyd Firestone,” an American engineer, began to apply this technique and received a patent. Itis this flaw detection technique that ultimately was used in medicine. An Austrian, Karl Dussik,” was probably the first to apply ultrasound for medical diagnosis in 1941. He ini- tially attempted to outline the ventricles of the brain, His approach used transmission ultrasound rather than re- flected ultrasound. After World War Il, many of the tech- nologies developed during that war, including sonar, were applied for peaceful and medical uses. In 1950, W. D. Keidel,* a German investigator, used ultrasound to ex- amine the heart. His technique was to transmit ultra- sonic waves through the heart and record the effect of ul- trasound on the other side of the chest. The purpose of his work was to try to determine cardiac volumes. The first effort to use pulse-reflected ultrasound, as described by Firestone, to examine the heart was initiated by Dr: Helmut Hertz of Sweden, He was familiar with Fire- stone's observations and in 1953 obtained a commercial ultrasonoscope, which was being used for nondestructive testing. He then collaborated with Dr. Inge Edler who ‘was a practicing cardiologist in Lund, Sweden. The two of them began to use this commercial ultrasonoscope to examine the heart. This collaboration is commonly ac- cepted as the beginning of clinical echocardiography as wwe know it today. The original instrument (Fig. 1.1) was quite insensi- tive, The only cardiac structures that they could record initially were from the back wall of the heart. In retro- spect, these echoes probably came from the posterior left ventricular wall. With some modification of their instru- ment, they were able to record an echo from the anterior leaflet of the mitral valve. However, they did not recognize the source of this echo for several years and originally at- tributed the signal to the anterior left atrial wall. Only al ter some autopsy investigations did they recognize the echo's true origin. Edler” went on to perform a number of ultrasonic studies of the heart, Many of the cardiac echoes currently used were first described by him. Ho ever, the principal clinical application of echocardiogra- phy developed by Edler was the detection of mitral steno- sis.!* He noted that there was a difference between the pattern of motion of the anterior mitral leaflet in patients, who did or did not have mitral stenosis. Thus, the early 12 Feigenbaum’s Echocardiography FIGURE 1.1. Ultrasonoscope initially used by Edler and Hertz for recording their early echocardiograms. (From Edler I, Ultra- soundcardiography, Acta Med Scand Suppl 370 1961;170:39, with permission.) studies published in the mid-1950s and early 1960s pri- marily dealt with the detection of this disorder, The work being done in Sweden was duplicated by a group in Germany headed by Dr. Sven Effert.?2 Their publications began to appear in the late 1950s and were primarily duplications of Edler’s work describing mitral stenosis. One notable observation made by Effert and his group” was the detection of left atrial masses. Schmitt and Braun: in Germany also began working with ultra- sound cardiography and published their work in 1958, again repeating what Edler and Effert had been doing. Edler and his co-workers* developed a scientific film that was shown at the Third European Congress of Cardiology in Rome in 1960, Edler et al.* also wrote a large review of cardiac ultrasound as a supplement to Acta Medica Scandinavica, which was published in 1961, and re- mained the most comprehensive review of this field for more than 10 years. In the movie and the review, Edler and his co-investigators described the ultrasonic tech- niques for the detection of mitral stenosis, left atrial tu- ‘mors, aortic stenosis, and anterior pericardial effusion. Despite their initial efforts at using ultrasound to ex- amine the heart, neither Edler nor Hertz really anticipated that this technique would flourish. Helmut Hertz was pri- marily interested in being able to record the ultrasonic sig nals, In the process, he developed ink jet technology and only spent a few years in the field of cardiac ultrasound, He devoted most of the rest of his career to ink jet tech- nology, for which he held many important patents. He also advised Siemens Corporation, who provided their first ul- trasonic instrument, that they should not enter the field of cardiac ultrasound because he personally did not feel that there was a great future in this area (Effert, personal com- munication, 1996). Edler too did not develop any further techniques in cardiac ultrasound, He retired in 1976 and until then was primarily concerned with the application of echocardiography for mitral stenosis and, 10 a lesser ex- tent, mitral regurgitation, He never became involved with any of the newer techniques for pericardial effusion or ventricular funetion. China was another country where cardiac ultrasound was used in the early years. In the early 1960s, investigators both in Shanghai and Wuhan were using ultrasonic devices to examine the heart. They began initially with an A-mode ultrasound device and then developed an M-mode recorder:*® The investigators duplicated the findings of Edler and Effert with regard to mitral stenosis.* Unique contributions of the Chinese investigators included fetal echocardiography” and contrast echocardiography using, hydrogen peroxide and then carbon dioxic In the United States, echocardiography was introduced by John J. Wild, HD Crawford, and John Reid” who ex- amined the excised heart, They were able to identify a my- cardial infarction and published their findings in 1957 in the American Heart Journal. Neither Wild nor Reid was a physician, Reid was an engineer who subsequently went to the University of Pennsylvania for his doctorate degree. While there, he wanted to continue his interest in examining the heart ultrasonically. He joined forces with Claude Joyner, who was a practicing cardiologist in Philadelphia. Reid proceeded to build an ultrasonoscope, and Joyner and he began duplicating the work on mitral stenosis that was described by Edler and Effert. This work was published in Circulation in 1963 and represents the first American clinical effort using pulsed reflected ultra- sound to examine the heart.” T became interested in echocardiography in the latter part of 1963. While operating a hemodynamic laboratory and becoming frustrated with the limitations of cardiac catheterization and angiography, I saw an ad from a now defunct company that was claiming that it had an instru- ment that could measure cardiac volumes with ultra- sound. This claim ultimately proved to have no basis, However, when I first saw the ultrasoand instrument played at the American Heart Association meeting in Los Angeles in 1963, I placed the transducer on my chest and saw a moving echo, which had to be coming from the pos- terior wall of my heart, This signal undoubtedly was the same echo that Hertz and Edler had noted approximately 10 years earlier: I had the people from the company ex- plain the principles by which such a signal might be gen- erated, I asked them whether fluid in back of the heart would give a different type of a signal, and they said that fluid would be echo free. When I returned to Indiana, I found that the neurologists had an ultrasonoscope that they used for detecting the midline of the brain. Fortu- nately for me, the instrument was rarely being used and I ‘was able to borrow it. I proceeded to examine more indi- viduals, and again I was able to record an echo from the back wall of the lelt ventricle. I looked for a patient with1. History of Echocardiography 3 pericardial effusion. As predicted, there were now two echoes separated by an echosiree space. The more poste- rior echo no longer moved, whereas the more anterior echo moved with cardiac motion, We went to the animal laboratory to confirm these findings and thus began my personal career in cardiac ultrasound. This initial paper on pericardial effusion was published in the Journal of the American Medical Association in 1965.” Although this phase of the history of echocardiography is commonly considered the origins of the early practice of echocardiography, it should be mentioned that Japan- ese investigators were working simultaneously using ul- trasound to examine the heart. In the mid-1950s, several Japanese investigators such as Satomura, Yoshida, and Nimura at Osaka University were using Doppler technol- ogy to examine the heart. They began publishing their work in the mid-1950s.= These efforts laid the basis for much of what we do today with Doppler ultrasound The field of cardiac ultrasound has evolved with the ef- forts of numerous individuals over the past 50 years. This development is an outstanding example of collaboration between physicists, engineers, and clinicians. Each of the cardiac ultrasonic techniques has its own individual his- tory. Even the name echocardiography has a story of its own, Edler and Hertz. first called this technique ulira- sound cardiography with the abbreviation being UCG. UL trasound cardiography was a somewhat cumbersome name, The most common use of medical diagnostic ultra- sound in the late 1950s and early 1960s was an A-mode technique to detect the midline of the brain. This midline echo would shift if there were an intracranial mass. The technique was known as echoencephalography, and the instrument was an echoencephalograph. It was such an instrument that I borrowed {rom the neurologists. If the ultrasonic examination of the brain is echoencephalogra- phy, then an examination of the heart should be echo- carciography. Unfortunately, the abbreviation for an echocardiogram would be ECG, which was already pre- empted by electrocardiography. We could not use the ab- breviation “echo” because it did not differentiate from an echoencephalogram. The reason the term echocardiogra- phy finally caught on was because echoencephalography disappeared. No other diagnostic ultrasound technique used the term echo except for the examination of the heart. So the abbreviation echo” now stands only for echocardiography and is not confused with any other ul- trasonic examination. DEVELOPMENT OF VARIOUS ECHOCARDIOGRAPHIC TECHNOLOGIES The story of echocardiography involves the evolution and development of its many modalities such as A-mode, M-mode, contrast, two-dimensional, Doppler, transesoph- geal, and intravascular applications. The Doppler story is truly lengthy and international, The Japanese began work- ing with Doppler ultrasound in the mid-1950s."* American ‘workers, such as Robert Rushmer in Seattle, were early in- vestigators using Doppler techniques. Dr. Rushmer was a recognized expert in cardiac physiology. John Reid later moved to Seattle and joined Rushmer and his group in de- veloping Doppler technology. One of the engineers, Donald Baker, was in that group and developed one of the first pulsed Doppler instruments." Eugene Strandness was a vascular surgeon in Seattle using Doppler for peripheral ar- terial disease.** European investigators were also very active in using Doppler technology: Several early French workers, namely Peronneau® and later Kalmanson,* wrote exten- sively on the use of Doppler ultrasound to examine the car- diovascular system. A major development in Doppler ultra- sound came when Holen® and then Hatle® demonstrated that one could derive hemodynamic information from Doppler ultrasound. They noted that one could use a mod- ified version of the Bernoulli equation to detect gradients across stenotic valves. The report that the pressure gradient of aortic stenosis could be determined with Doppler ultra- sound was probably the development that established Doppler echocardiography as a clinically important tech- nique. The field of contrast echocardiography began with an unexpected observation by Gramiak et al."' at the Univer- sity of Rochester. They apparently were doing an ultrasonic examination on a patient undergoing an indicator dilution test using indocyanine green dye. Much to their surprise, they noticed a cloud of echoes introduced into the cardio- vascular system with the injection of dye. Apparently, Joyner had noticed a similar observation with the injection of saline but did not report the finding. I heard Gramiak present his group’ work at a meeting and promptly used that technique to help establish the echocardiographic identity of the left ventricular cavity? Workers at the Mayo Clinic headed by Jamil Tajik and Jim Seward went on to use this contrast technique in a very eloquent way to iden- tify right-to-left shunts. Contrast agents have evolved to the current commercial products, which are manufac- tured. The tiny echo-producing bubbles are small enough to pass through capillaries so that peripheral injection can be seen on the left side of the heart. ‘Two-dimensional echocardiography has a lengthy and fascinating history. As with almost every aspect of eardiae ultrasound, there is an international flavor to this story. ‘Two-dimensional ultrasonic scanning dates back to early workers such as Douglass Howry when he began using compound scanning for various parts of the body. One of his early compound scanners used a transducer that was mounted on a ring from a B29 gun turret.* The Japanese introduced a variety of ultrasonic devices to create two- dimensional recordings of the heart.** They used elabo- rate water baths and scanning techniques (Fig. 1.2). Gramiak and co-workers" at the University of Rochester used reconstructive owo-dimensional M-mode techniques