Journal of X-Ray Science and Technology 11 (2003) 133–139 IOS Press


Cardiovascular ultrasound imaging – A survey of technical development
Zheng F. Lu
Radiology Department, College of Physicians & Surgeons of Columbia University, 177 Fort Washington Avenue, MHB 3-265B, New York, NY 10032, USA Tel.: +1 212 305 9020; Fax: +1 212 342 0927; E-mail:
Abstract. This article reviews the physics fundamentals in cardiovascular imaging using ultrasound and discusses the current technology and advances in clinical practices. Challenges in future development are included at the end of the article.

1. Pros and cons of ultrasound in cardiovascular imaging The proportion of ultrasound studies is estimated to be more than one out of every four medical imaging studies in the world [1]. The reasons for its popularity are numerous. Perhaps the main reason is derived from the safe nature associated with ultrasound and the fact that the equipment is low cost, mobile, and convenient to use. Compared to other imaging modalities, such as MRI and CT, ultrasound imaging offers a superior temporal resolution that is crucial in cardiovascular studies. The ultrasound technology has been widely applied in cardiovascular imaging in assessing morphological and haemodynamic processes. For example, volumetric echocardiography provides quantitative diagnostic information, or at least semi-quantitative diagnostic information, such as cardiac function assessment; Doppler ultrasound has been utilized to analyze blood flow patterns and has played a crucial role in assessing cardiovascular diseases. The main disadvantage of ultrasound is its difficulty in the presence of bone or gas. Since the acoustic impedance of bone or gas is significantly different from the acoustic impedance of soft tissue, a majority of the ultrasound is reflected at any interface encountering bone or gas. A so-called “acoustic” imaging window is needed where no bone or gas is in the path of the ultrasound beam. Such an acoustic imaging window is not always available. In cardiovascular imaging, small footprint transducers (see Fig. 1a) are utilized to fit in the space between the ribs for the acoustic window. Consequently, the visualization of the heart is limited from certain angles due to the restricted acoustic window. There are alternative ways for ultrasound transducers to approach the heart. For example, a transesophageal transducer can be intubated through the esophagus (see Fig. 1b) [2]. This type of transducer, however, is relatively invasive, and the procedure can be time-consuming. Another disadvantage of ultrasound is its operator and instrumentation dependence. Since ultrasound technique is extremely interactive, both image acquisition and interpretation require a high level of skill. Although there may be “presets” on the system, adjustment has to be made in order to optimize image quality according to each individual exam condition.
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Z.F. Lu / Cardiovascular ultrasound imaging – A survey of technical development


Fig. 1. (a) Picture of an adult transthoracic echocardiography transducer (courtesy of Siemens Medical Solutions). (b) Picture of a transesophageal biplane echocardiography transducer. The tip diameter is only 9 mm. (courtesy of Siemens Medical Solutions).

2. Current technology of 2-D echocardiogram The 2-D echocardiogram is based upon pulse-echo techniques that map the acoustic properties of insonified tissues [3]. An ultrasound transducer converts electric energy into ultrasound energy and vice versa. The transducer emits a very short ultrasound pulse, usually only 1–2 µsec long, into the patient’s body. As the ultrasound pulse propagates through tissue, echo signals are generated as a result of mechanical interactions of the sound waves and reflections occurring in the patient’s body. The returned echo signals are acquired by the same transducer and utilized to form an acoustic line. The brightness along the display line is modulated according to the amplitude of the received echoes. The location where the echo signal is generated is determined based upon the time delay between the pulse emitting and the echo receiving. If D is the depth where the echo signal is generated, t is the time delay and c is the speed of sound propagation, then
D= ct . 2


This is called the range equation upon which echo signals are localized. For ultrasound systems, the speed of sound propagation is assumed to be 1.54 mm/µs – the average speed of sound for soft tissues. In order to form a 2-D image, the acoustic line is swept through a cross-sectional region of interest. The

Z.F. Lu / Cardiovascular ultrasound imaging – A survey of technical development


Fig. 2. A 2-D echocardiogram along with the M-mode image visualizing a left ventricle from a parasternal long axis view (courtesy of GE Medical Systems).

sweeping lines are utilized to create a tomographic slice of the acoustic map of the cross-section that is called 2-D echocardiogram (see the upper panel in Fig. 2). The frame rate of a 2-D echocardiogram is ultimately limited by the sound propagation speed. The maximum frame rate is inversely proportional to the time needed for ultrasound pulses traveling down and echo signals propagating back from the maximum depth of the field of view, and the total number of acoustic lines per frame. Compared to the 2-D echocardiogram, the M-mode has a much better temporal resolution, because in M-mode, only one acoustic line is repeatedly collected over the scanning time. The brightness of the display line is modulated according to the amplitude of the received echoes, similar to the 2-D echocardiogram [3]. Figure 2 shows a 2-D echocardiogram of a left ventricle from a parasternal long axis view in the upper portion of the image display, and the M-mode in the lower portion of the display. The acoustic line depicted by the M-mode is localized on the 2-D echocardiogram by the dashed line. In the M-mode configuration, the echo signals of a single acoustic line are presented along the vertical axis of the display, and the successive lines over the scanning time are displayed along the horizontal axis progressively. For a stationary object, its trace is a straight horizontal line. However, if an object is moving, the movement is shown as vertical displacements recorded by the successive lines and appear on the image as wavy patterns. These patterns can be utilized to calculate the velocity of motion.


Z.F. Lu / Cardiovascular ultrasound imaging – A survey of technical development

3. Current technology of Doppler ultrasound Measuring blood velocity is a unique feature of ultrasound technology. When sound waves interact with moving blood cells, the frequency of the echo signal changes from the original wave frequency emitted by the transducer. This frequency change is called Doppler frequency shift. In the Doppler ultrasound mode, the flow velocity can be derived from the Doppler frequency shift by the following relationship [3]:
v= cfD 2f0 cos θ


where v is the blood velocity, c is the speed of sound propagation, f D is the Doppler frequency shift, f0 is the original wave frequency emitted by the transducer and θ is the angle of the flow relative to the ultrasound beam. There are various Doppler ultrasound configurations including continuous-wave (CW) Doppler, pulsed Doppler, color Doppler and power Doppler [3]. The CW Doppler instruments are the simplest, and often the least expensive Doppler devices available. However, no specific spatial information is provided regarding the exact location where the Doppler signals are generated. With more sophisticated Doppler systems, such as pulsed Doppler, a range gate is applied to select the sample volume for flow measurements. The limitation of pulsed Doppler is that only a small volume is segmented for Doppler signal analysis. In order to view 2-dimensional flow mapping in a region of interest, the color Doppler or the power Doppler should be employed. In the color Doppler configuration, the flow velocity is estimated and color coded. In contrast to the pulsed Doppler, the color Doppler does not correct for Doppler angles. Consequently, the accuracy of the velocity measurement is greatly compromised and the color Doppler is angle dependent. Figure 3 shows a duplex display: the 2-D echocardiogram and the spectral Doppler display of a prosthetic mitral valve. The color Doppler of the region of interest is superimposed upon the 2-D echocardiogram in the same image. The power Doppler is a more recent development in ultrasound imaging [3]. Unlike the color Doppler, color in the power Doppler is coded according to the amplitude of the Doppler signals, instead of the estimation of the flow velocity. Since the amplitude of the Doppler signals is displayed, the power Doppler is not angle dependent, and its sensitivity is better. The power Doppler is often utilized to show a 2-dimensional structural view of the vascularity.

4. Current advances in clinical practices In order to display the heart as a realistic three-dimensional object, 3-D echocardiography has been developed [4–6]. Before 3-D echocardiography became available on the system, the only way for cardiologists to obtain 3-D images of complex cardiac pathology was to perform tedious mental reconstructions from the multiple 2-D sequential slice images. This practice is inefficient and may introduce variability in the diagnosis. Later on, with the benefits of high performance computers, the 3-D echocardiography has been reconstructed within a much shorter time on the system. One important advantage of the 3-D echocardiography is that the entire spatial and morphological information of the heart in one or multiple heartbeat cycles can be contained in one 3-D data set; thus the cardiologist can retrieve all the desirable cardiac cross-sections without having to recall the patient. With the 3-D visualization software, the objects can be rotated and accessed from any orientation including those which are difficult for 2-D

Z.F. Lu / Cardiovascular ultrasound imaging – A survey of technical development


Fig. 3. Duplex display of a 2-D echocardiogram and spectral Doppler display indicating a ventricular septal defect (courtesy of Siemens Medical Solutions).

echocardiography to access. This allows more accurate and reproducible measurements of the complex cardiac examination, such as quantitative evaluation of left ventricular function. Currently, the 3-D echocardiography does not provide the same spatial and temporal resolution as the 2-D echocardiography. This may be problematic, when 3-D echocardiography is utilized in depicting subtle irregularities [7]. Recent updates in ultrasound contrast agents have improved image quality significantly, especially in those patients whose ultrasound scans were, otherwise, not optimal. Studies have been performed to improve the border delineation of the endocardium using ultrasound contrast agents [8]. In many cases of cardiovascular ultrasound imaging, ultrasound contrast agents have a major potential role to play [9,10]; for example, to enhance the non-invasive assessment of cardiac function, to better visualize the left ventricular endocardial border, and to determine the levels of myocardial perfusion. The new technique of pulse-inversion harmonic imaging provides even more enhancement in image quality [10]. 3-D echocardiography is a rapidly advancing field. Compared to 3-D CT and MRI, 3-D ultrasound can acquire 2-D slices at a much higher rate; thus dynamic 3-D (i.e., 4-D) visualization is possible [6]. This is particularly promising in cardiovascular ultrasound imaging. It is likely that 3-D echocardiography will become a routine tool in echocardiography examination in the future, although more advances are required in both software and hardware. Future technical research will be in the direction of numerous potentials: e.g., “online” navigation, teaching and training, developing a virtual reality model for surgical planning, quantitative package for accurate and reproducible measurements [5,11,12]. The combination of higher frequency, better ultrasound transducer beam forming, and advanced signal processing allows more potential clinical applications in cardiovascular imaging. An example is the non-invasive assessment of coronary flow reserve (CFR) [13,14]. CFR is defined as the ratio of maximal to basal coronary flow. Because it is reduced substantially in diseased vessels, this parameter is proven


Z.F. Lu / Cardiovascular ultrasound imaging – A survey of technical development

to be a good indicator of vessel condition. Therefore, an accurate and reproducible measure of CFR provides valuable information regarding microvascular coronary circulation. The conventional validated tool for CFR assessment with ultrasound is invasive, using intracoronary Doppler [15]. Modalities other than ultrasound, such as PET [16] or MRI [17], have been employed to measure CFR non-invasively. In recent years, studies have been performed to develop non-invasive ultrasound technique for this purpose. Transthoracic Doppler echocardiography has shown great promise [13,14]. 5. Emerging technologies in clinical practices There are a number of emerging technologies for potential clinical applications in the future. One example is to image the regional difference in myocardial function [18]. Tissue Doppler Imaging has been utilized to image the regional pathological features in functioning myocardium by locally measuring radial and longitudinal myocardial velocities [19]. This is achieved by differentiating the amplitude of Doppler signals; keeping the high amplitude Doppler signals from myocardium and discarding the low amplitude Doppler signals from blood cells. A new technology – strain rate imaging goes beyond the local myocardial Doppler velocity data and derives the regional myocardial deformation [20,21]. Compared to other non-invasive methods of measuring myocardial deformation, such as MRI tagging, ultrasound strain rate imaging has a superior temporal resolution. The major disadvantage with this method is that the deformation estimation is along the ultrasound beam axis only; thus it is angle dependent. One remedy for this problem is to estimate the tissue velocity in multiple dimensions. This will become possible when 3-D strain rate imaging is available in the future [20]. Ultrasonic characterization of cardiovascular tissue has evolved for more than two decades and there are numerous publications on cardiovascular tissue characterization in vivo [22,23]. The goal of tissue characterization is to differentiate abnormal pathologic structure and function from normal. The hypothesis is that pathologic changes can be quantified through ultrasound parameters, such as attenuation and backscatter coefficients, and such quantification will provide information that is independent from the instrumentation and operator factors. Unlike conventional echocardiography, where only the envelope detected video echo data is utilized in image formation, radiofrequency echo signals are needed for this kind of sophisticated signal processing. The major challenge for ultrasound tissue characterization is in the complexity and diversity of biological tissues. A more futuristic application of ultrasound is in local drug delivery [24]. If a drug is encapsulated in microbubbles designed especially for drug delivery, it can be moved around throughout the circulatory system, and be delivered at a targeted region. Ultrasound can be utilized to induce microbubble destruction; thus activate the targeted drug delivery. Although this application may appear speculative now, the feasibility of this technology has been proven by early studies [25]. In conclusion, ultrasound is an essential component of cardiovascular imaging with tremendous potentials for further development. The subjects of current frontier research have shown great promise in more cardiovascular applications, such as 3-D echocardiography and strain rate imaging discussed above. If we put the future of ultrasound imaging in perspective, will the development of other imaging modalities, particularly MRI and PET, become a threat to the current predominant role of cardiovascular ultrasound? We believe ultrasound will continue to play an essential role in cardiovascular imaging. The superior temporal resolution of ultrasound is unmatched by other modalities. In addition, ultrasound is mobile and less costly. Ultrasound studies are convenient and highly acceptable to patients. Although there has been precaution on ultrasound biological effect [26], ultrasound is still regarded very safe for all current clinical applications; unless future technology leads us in the direction of employing much higher acoustic output than the current level.

Z.F. Lu / Cardiovascular ultrasound imaging – A survey of technical development


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