arm == D The Echocardiographic Examination The ability to record high-quality echocardiographic im- ages and obtain accurate Doppler flow recordings are es- sential determinants of the overall value of the echocar: diographic examination. As such, echocardiography is highly operator dependent. Itis difficult to overemphasize the critical role of the person who performs the imaging. Echocardiography can also be regarded as a partnership between the individual who obtains the data and the one who interprets the study. To obtain a comprehensive and accurate echocardiogram, the operator must understand the anatomy and physiology of the cardiovascular system, have a thorough knowledge of the ultrasound equipment to optimize the quality of the recording, know the specific diagnostic questions that are being asked, and be able to apply the technology to the individual patient so that op- timal imaging can be achieved. Echocardiography is a highly versatile technique that can be applied in variety of clinical settings. Patients are usually referred for an echocardiogram to investigate symptoms or abnormalities found on a physical examina- tion, to evaluate a known or suspected clinical condition, ‘ 10 sereen a subject for the possibility of disease. The value of the diagnostic information depends on the qual- y of the study and the likelihood that the results will pro- vide new information that will have an impact on the pa- tient’s management or well-being. Guidelines have been published jointly by the American Heart Association, the American College of Cardiology, and the American Soci- ety of Echocardiography that critically evaluate the strength of evidence for the use of echocardiography in various clinical situations. Throughout this book, the rec- ‘ommendations provided by these guidelines are high- lighted. These guidelines are based on the weight of evi- dence that supports the utility of the test and the consensus of a panel of experts. The recommendations concerning the use of echocardiography use the following classification system: Class I: Conditions for which there is evidence and/or gen- eral agreement that a given procedure is useful and ef- fective. Class I: Conditions for which there is conflicting evi- dence andior a divergence of opinion about the useful- nesslefficacy of a procedure. Class Ha: Weight of evidencelopinion is in favor of useful- nessielficacy. Class IIb: Usefulnesslefficacy is less well established by evidencelopinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure is not usefull effective and in some cases may be harmful. ‘An example of this classification system provides a guide for the general use of echocardiography for the evaluation of patients with a heart murmur (Table 5.1). Most echocardiographic examinations are comprehen- sive. That is, a thorough and fairly standardized approach is undertaken with the goal of recording a complete array D TABLE 5.1 Indications for Echocardiography the Evaluation of Heart Murmurs Class 1. A mutmur in 8 patient with eardiorespiratory 1 ‘symptoms 2. A mutmur in an asymptomatic patient ifthe f clinical features indicate atleast a moderate probability thet the murmur is eflactive of structural heart disease 3. A mutmur in an asymptomatic patient in whom Ma there is alow probabilty of heart disease butin whom the diagnosis of heart disease cannot be reasonably excluded by the standard cardiovascular clinical evaluation 4. Inan adult an asymptomatic heart murmur that M has been identified by an experienced observer as functional or innocent ‘Adopted from Cheldn MD, Alper JS, Armstrong WF, etal. ACC/AKA Guide Appleton af Eehoeerdiography a report ofthe Amer- jology/American Heart Association Task Force on Prac> 5 (Carma on Clinical Application of Echocardiography) developed in collaboration with tha American Social a Echocardiography. Circulation 1997,9:168-1744, with permission. 105106 Feigenbaum’s Echocardiography ‘of images and Doppler data that address the full spectrum, of possible diagnoses (Table 5.2). Occasionally, a more tar- geted or focused examination is undertaken that is only concerned with a specific diagnostic issue, often compar- ing the current situation with a recent examination. In other situations, an entirely different approach is required, such as when evaluating an infant with suspected complex, congenital heart disease. Clearly, echocardiography re- quires an individualized approach and each patient represents a unique set of problems and challenges. The technical details involved in obtaining a high-quality echocardiogram are unique, and the examination must be customized for each patient. It is not feasible to simply place the transducer at routine locations on the chest and expect standardized, high-quality images to be available in each patient. The examiner must rely on experience, per- sistence, and creativity to record the most comprehensive and highest quality data. Additional factors, including transducer selection, instrument settings, patient comfort and positioning, and even the patient’ breathing pattern will also affect the quality of the recording. TABLE 5.2 Transthoracic Echocardiograp Two-Dimensional Imaging _ Doppler Imaging Parasternal Parasternal Longraxs MIR, AR, VSO Medially angulted ong axis AV inflow, TR Short-axis (muitisle levels) ‘AR, TR.PS, PR, VSO Basal MR MY level Papillary muscle evel Apical Apical Apical Four-chamber Mito, trcuspid into, MR, TR Two-chamber Mitral infiow, MR Longraxis MR, AR, AS, VOT Five-chamber LV outflow, AR, AS, IMRT Subcostal Subcostal Four-chamber AV inflow, TR, ASD Short-axis Basal TR.PS, PR Mid-vonticular INC, hepatic veins Suprasternal Suprasternal Aortic arch in long-axis ‘Ascending/descending aortic ow, Aortic arch in short-axis AAR, POA, SVC Right parasternal Right parasternal Ascending arta aS AR, aortic regurgitation; AS, aortic stonosis; ASO, atl septal dfect IV, in ‘orior vena ceva; VAT, isovolumic elexetion time; LY let ventricle; LOT, left ventricular outflow tact MR, mitral regurgitation, MU, mitral valve; PDA, patent ductus arteriosus; PR, pulmonic regurgitation; PS, pulmonic stenosis AY, ight ventricle; SVC, superior vena cave, TR, tricuspid regurgitation; VSD, vonvicular septal defect. SELECTING THE TRANSDUCERS Most ultrasound systems are equipped with a selection of transducers with a range of capabilities and limitations. With the exception of dedicated continuous wave Doppler (called nonimaging or Pedofi) transducers, most probes, are capable of performing M-mode, two-dimensional, and Doppler imaging (Fig. 5.1). It is rare that one transducer is ideal for every aspect of a given examination. For in- stance, a high-frequency imaging transducer may provide optimal resolution for nearfield imaging (such as the right ventricular free wall or the cardiac apex) but will of- fer inadequate penetration to allow imaging of the far field, In a large patient, the apical window may place the left atrium as far as 20 cm from the transducer. For ade~ quate visualization, a relatively low frequency transducer will be necessary. The best Doppler studies are generally obtained with lower frequency transducers. It may be necessary to switch from one transducer to another to take advantage of the capabilities of each. Some modern transducers provide a range of frequencies or allow selec- tion of different frequencies as an added convenience. The frequency of the transducer used for cardiac imaging often depends on body habitus and patient size. For large patients or thick-chested individuals, a 2.0- or 2.5-MHz. transducer may be necessary to provide adequate pene- tration. Children and smaller adults can generally be ade- quately imaged using a 3.5- or even 5.0-MH transducer: For infants and children, a 7.0- or 7.5-MHz transducer is often ideal. In addition to transducer frequency, transducer size or “footprint” is also a consideration. The footprint refers to the dimensions of the surface area coming in contact with the patient’s skin. Because of the relatively narrow spaces between the ribs, the footprint can be a limiting factor in transducer selection (Fig. 5.2). In this illustration, the dis- tal septum and posterior left ventricular wall are obscured FIGURE 5.1. A varieiy of wansducers are available for use in clinical echocardiography. A transesophageal transducer and five wansthoracic probes are illustrated.5. The Echocardiographic Examination 107 by the rib shadow along the left side of the image. If the transducer surface is to0 big to fit between ribs or to maintain continuous contact with the skin, suboptimal imaging will be obtained. PATIENT POSITION The transthoracic examination can be performed with the echo pher (or sonographer) sitting on the pa- tient’ left or right side. This is largely a matter of personal preference, comfort, and custom. When seated to the t side of the patient, scanning is performed with the ht hand. If the left side is used, usually the operator scans with his or her left hand and manipulates the ma- chine settings with the right hand. Developing experience Lr | FIGURE 5.2. An example of rib shadowing is demonstrated (arrows). The presence of the rib rel ative to the transducer footprint obscures the distal septum and posterior wall of the left ventricle (LV). LA, left atrium; RV, right ventricle. scanning from both sides is recommended. Not only does this minimize the risk of repetitive-use injury, but it pre- pares the sonographer for room situations where only one side of the bed may be available for approaching the patient One of the goals of the echocardiographic examination is to obtain the highest quality images without creating unnecessary discomfort or anxiety for the patient. Bi cause transthoracic echocardiography can take as long as an hour, the comfort and well-being of both the examiner and the patient are important. The transthoracic echocar- diographic examination usually requires more than one patient position. For most adult patients, imaging is per- formed with the patient either supine and/or tilted in the lefi lateral decubitus position (Fig, 5.3). By tilting the pi tient to the left, the heart is brought forward to the chest FIGURE 5.3. Proper positioning for the echocardio- graphic examination is demonstrated, The transducer is placed over the apical window, and the patient is tilted |= inthe left lateral decubitus position