Q@iymwmm > Specialized Echocardiographic Techniques and Methods Cardiac ultrasound or echocardiography is a diagnostic technique by which ultrasound is used to display anatomic and physiologic characteristics of the cardio- vascular system. The basic principles of interaction of ul- trasound with tissue and blood and the basic mechanisms by which an image is created are discussed in Chapter 2 Echocardiography consists of several different imaging “domains” or display methodologies. The commonly used clinical imaging domains are listed in Table 3.1. Each of these ultrasound methodologies has specific strengths and weaknesses, and there are specific clinical arenas in which one technique may play a predominant role. Each imaging modality uses the same basic principle of reflec- tion of sound in the ultrasonic frequency range to register data, conveying information regarding the presence and location of a reflective boundary or the direction and ve- locity of a moving target such as red blood cells or tissue. Information from any of these methodologies can be gathered using ultrasound transducers of varying capabil- ities and delivering diagnostic ultrasound to cardiac structures via a variety of routes. IMAGING DEVICES AND METHODS M-Mode Echocardiography {ultrasound image was obtained using a single interrogation beam from a dedicated transducer. Basi- cally, ultrasound energy is sent out from the transducer as an ultrasound packet that is then reflected back to the transducer. Transmission of ultrasound from the trans- ducer is not continuous but rather interrupted, with the nontransmit time being used to receive the signal. When used in this method and directed into the thorax, the ul- trasound along the single line of interrogation is reflected from cardiac structures and registered as a series of re- flective interfaces. Ifthe location and strength of these in- terfaces are then plotted over time, typically by recording the continuous returning signal on a strip-chart recorder 46 D TABLE 3.1 Imaging Domains for Clinical Echocardiography Anatomic imaging domain Single-line interrogation M-mode echocardiography ‘Mutiple-tine interrogation Two-dimensional echocardiography ‘Motiple-dimensional imaging Three-dimensional imaging Reconstructed Real-time three-dimensional imaging Doppler dom Pulsed Doppler methods. interrogation volume Saturated interrogation volume area Color flow imaging ‘M-mode color interrogation ‘Continuous wave Doppler Analysis domains Frequency shift Power spectrum Variance Correlation methods Tissue velocity imaging Strain rate imaging or scrolling video screen, then an M-mode echocardio- gram is recorded (Fig. 3.1). The term M-mode refers to the motion that is derived from the time component. Some older references have referred to this methodology as a time-motion mode (T-M mode). Because M-mode echocardiography interrogates only along a single line, it does not provide a rapid anatomic screening method. An- other limitation is that the true orientation of the beam with respect to accurate cardiac anatomy is often not known if a stand-alone transducer is used. Advantages of M-mode interrogation include high temporal resolution, (1,000-3,000 Hz compared with 20-60 Hz for traditional,3. Specialized Echocardiographic Techniques and Methods 47 ene Poa FIGURE 3.1. M-mode echocardiogram recordet ‘elt ventricle at the level of the mitral valve tips. wwo-dimensional echocardiography). Additionally, the spatial resolution along the single line of interrogation is, higher than that of two-dimensional echocardiography This was of clinical relevance when using tion two-dimensional ultrasound devices. Current devices using harmonic imaging or high-frequency transducers provide spatial resolution clinically equivalent to that available from M-mode echocardiography. They do not, however, provide the temporal resolution of M-mode echocardiography, which is suited to identifying brief rapid motion or fine oscillatory motion, such as that seen with mitral valve diastolic flutter in patients with aortic insufficiency, aortic valve systolic notching in dynamic outflow obstruction, and subtle abnormalities of wall mo- tion as seen in conduction disturbances. ‘Two-Dimensional Echocardiography Two-dimensional echocardiography provides an ex panded view of cardiac anatomy by imaging not along a single line of interrogation but along a series of lines typ- ically spanning a 90-egree arc (Fig. 3.2). In modern scan ners, any of the additional domains of imaging such as M- mode and Doppler can be simultaneously performed and superimposed on the two-dimensional image or other- wise simultaneously displayed. Color B-mode Scanning For routine two-dimensional imaging (B-mode), the im- age typically is displayed in gray scale. Although first- generation scanners were limited to 16 shades of gray and, FIGURE 3.2. Transthoracic two-dimensional echocardiogram recorded in a parasternal long-axis view revealing the right ven: tricle, left ventricle, left atrium, and proximal aorta as well as septal and posterior wall thickness (double. headed arrows) @ later scanners to 64 shades, current instruments display 256 shades of gray. This degree of gray-scale range ex- ceeds the eye's ability to discern differences, An alternate mode of display is to convert the gray scale assignments toa range of color or of hue within a color (color B-mode) (Figs. 3.3 and 3.4), Studies have suggested that this may enhance detection of subtle soft-tissue density targets, DOPPLER INTERROGATION Whereas two-dimensional structural imaging relies on analysis of the time of transit and intensity of a returning ultrasound signal to identify an anatomic structure, Doppler interrogation relies on analysis of a change in the frequency of the transmitted ultrasound. Initially, this was displayed as the actual frequency shifi. The magnitude of frequeney shift is in the kilohertz range. This frequency shift can be converted to velocity of the interrogated tar- get by the Doppler equation. Virtually all modern instru- mentation provides this computation online, and it is the actual velocities that are displayed rather than frequency shifts. Doppler is used in multiple different formats. The first Doppler format to be clinically used was a spectral display of the returning frequency shifts, which, as noted previously, is converted to velocity on all modern clinical scanners. This is typically displayed with refer ence to a zero crossing line, Any signal above that line rep- resents motion toward the transducer, and any signal be low the line represents motion away from the transducer. ‘The magnitude of the frequency shift is directly related to velocity by the Doppler equation.48 — Feigenbaum’s Echocardiography FIGURE 3.3. Transesophageal echocardiogram concentrating on the left atrial appendage in a patient with atrial fibrillation, demonstrating the effect of B-mode color. Top: This image was recorded in routine gray scale; middle and bottom: B-mode color was used. Note the more obvious nature of the left at appendage thrombus and associated spontaneous con trast in the B-mode color images. FIGURE 3.4. Apical four-chamber view recorded in a patient with the apical variant of hypertrophic cardiomyopathy in rou tine gray scale (top) and with B-mode color (bottom) Note the more obvious nature of the apical hypertrophy in the B-mode color im Any of the Doppler methodologies can be simultane- ously performed with anatomic two-dimensional imaging by sharing the computational resources of the ultrasound instrument. The spectral Doppler display can then be dis- played simultaneously with the two-dimensional image. Early instrumentation did not have the computational power to perform both of these analyses simultaneously and often anatomic imaging was suspended during Doppler interrogation. shortcoming and can simultaneously display real-time, two- dimensional imaging and Doppler interrogation (Fig. 3.5). Spectral Doppler imaging is acquired through two dif- ferent methods, continuous and pulsed wave (Fig. 3.6). As the name implies, continuous wave Doppler imaging con- tinuously transmits and receives the ultrasound signal. Because it is continuously transmitting and receiving, the ability to determine the time of transit is lost and only the frequeney shift of the returni results in a phenomenon known as range ambiguity, in which the precise velocity of motion can be calculated but not the precise location at which that velocity occurred. Modern instrumentation overcomes. this signal is calculated. This