Knobology and Image Optimization

Objective
Accurate interpretation of an ultrasound image using different echocardiographic modalities requires an
initial fundamental understanding of echocardiographic instrument configuration and operation. The objective of
this lecture is to review the basic knobology of a typical echocardiography console and to provide a foundation
of knowledge to enable accurate ultrasound data acquisition and image enhancement.
Transesophageal Echocardiographic (TEE) Probes
The TEE probe resembles a flexible gastroscope that can be manipulated in the anterior/ posterior and
right/left lateral directions by rotating two knobs at its proximal end on the handle. The ultrasound transducer(s)
are located at the tip of the probe and are composed of piezoelectric crystals that can both generate and receive
ultrasonic waves. The crystals emit ultrasound by alternatively compressing and expanding with the application
of alternating current. The ultrasonic waves received by the piezoelectric crystals are similarly electrified,
amplified, processed and eventually displayed on a video screen for interpretation.
Multiplane probes have a single transducer that can be electrically rotated by adjusting a switch at the
proximal end of the probe. These transducers can be rotated from 0 - 1800 to obtain multiple imaging planes
relative to the long axis of the esophagus. The type and/or position of the imaging plane is indicated on the video
screen.The TEE probe is connected to the front of the echocardiography console by inserting, securing and
latching it into position beneath the keyboard.
The Ultrasound Machine
The standard echocardiography machine consists of a portable unit with a video monitor, keyboard
controls for data entry, a panel of knobs and switches for optimizing image acquisition and interpretation, and a
track ball. Several optional recording devices are often integrated into the system including a VCR recorder,
image printer, hard drive, optical disc, etc.
Once the machine has been plugged in and turned on, it will perform a self-test as an initial check of
internal diagnostics and computer software. Pressing the <BEGIN> button on the console will allow for patient
demographic and preliminary data entry. (i.e., name, hospital number, procedure, etc.) . Pressing <BEGIN
IMAGING> or <END> will result in changing the video display to the 2-D imaging mode. The video monitor
display can be adjusted for black/white and hue/contrast to compensate for changes in ambient lighting. The
adjustments will only affect the appearance of the images on the video screen or video tape and do not alter the
sound intensity generated or received by the probe. An EKG tracing for timing cardiac events will also be
displayed on the monitor assuming that it has been plugged into the console from chest leads or an auxiliary
input from an operating room monitor.
Echocardiography Imaging Modes
The two most commonly used echocardiographic modes for cardiac imaging are 2-D (B-mode) and Mmode imaging. The 2-D image is reconstructed from information acquired by an ultrasound beam sweeping
across the sector of interest using multiple beams generated by a phased array transducer that consists of multiple
elements. The line density determines the overall lateral resolution of the image. The frame rate (the number of
images produced and updated per second) will determine how smooth the image appears and depends upon
image depth, width and scan line density. Decreasing the depth and width of the sector allows for a higher frame
rate and improved image resolution.
Pressing the M-mode button on the console results in the display of single dimensional, ice-pick view
of cardiac structures over time. A small 2-D image is simultaneously displayed indicating the orientation of the
interrogating ultrasound beam corresponding to the M-mode sector. With only a single ultrasound beam, Mmode can utilize much higher sampling rates than 2-D imaging and allows for more precise measurement of
events with a temporal component and greater definition of rapidly moving structures.

2-D and M-Mode Imaging Controls:

Gain: Increasing the <GAIN> increases the intensity of the generated ultrasound wave, the
amplification of the received signal by compensating to a degree for attenuation, and the brightness of
the image. This button is analogous to the brightness function of a television set. If the gain is too
high, excessive brightness of the white and gray elements obscures the fine details of the image.
Conversely, if the gain is set too low, the image will appear too dark to define certain structures. The
optimal gain should be set to the lowest intensity while still preserving image quality.
Depth: Adjusting the <DEPTH> changes the penetration distance (centimeters) and affects the
frame rate of the image and the pulse repetition frequency (PRF - the number of times the piezoelectric
crystal is electrically stimulated per second). Decreasing depth increases the PRF and frame rate
thereby decreasing the time to scan an area of interest and increasing the number of lines that can be
scanned. Images in the near field are therefore better visualized at lower depth settings since less time
is spent waiting for return signals.
Depth (Time) Gain Compensation (DCG/TCG): The horizontal <DCG> levers on the console
can be used to vertically adjust gain to compensate for temporal changes associated with variation of
ultrasound beam penetration at increasing depths. Sliding the lever from left to right increases the gain
for a specific depth. In general, the near field gain is set lower to compensate for stronger reflected
waves. Conversely, the far field gain is set higher to compensate for weaker reflected waves due to
attenuation associated with absorption, refraction and scattering by tissues. Lateral Gain Control is also
available on some consoles.
Compression (DYNAMIC RANGE): Changing the <COMPRESSION> alters the range of
returning ultrasound signals that will fall within the dynamic range of reflected echo signal intensities.
The intensity of the reflected signal is displayed on the video screen as different shades of gray ranging
from white to black. Increasing the compression excessively increases the intensity of certain grayscale pixels creating snow on the video display. Inadequate compression compromises contrast and
tissue definition. The compression should increased/decreased just until fluid filled cavities appear
black.
Transmit Focus: Adjusting the <TRANSMIT FOCUS> optimizes the resolution designated by
the caret (arrow head) alongside the depth markers on the lateral border of the image sector. Toggling
the paddle switch adjusts the focal zone of the transmitted signal to improve resolution in the near or far
field.
Resolution (RES / ZOOM): Pressing the <RES> button enables magnification and enhanced
resolution of a selected 2-d image viewed in real time. Pressing the switch the first time allows for
optimizing the size and position of a wedge shaped box superimposed over the designated area of
interest. Pressing the switch a second time magnifies and increases the resolution (number of scanned
lines, sweep rate and smoothing) of the structures within the box. Pressing the switch for the third time
returns the video display to the previous, original 2-D image.
Size: Changes the <SIZE> of the image independent of depth or resolution.
Persistence: <PERSISTENCE> adjusts the updating and averaging of consecutive frames (30
60 fps) on the screen to reduce noise and speckling. Averaging previous frames has the advantage of
smoothing out the displayed image but sacrifices crispness of moving structures. In general, higher
levels of persistence are more desirable for slow moving structures and lower levels more appropriate
for rapidly moving structures.
Postprocessing: The relationship between the ultrasound wave amplitude and the displayed
gray-scale pixel intensity is defined by a <POSTPROCESSING> curve. Either a predefined or custom
postprocessing curve can be selected.

Frequency (MULTIHZ): Commonly used transducers have frequencies in the range of 3.5 to
7.5 megahertz. Since the velocity of a propagating sound wave is relatively constant throughout human
tissues, varying the frequency of the ultrasound wave changes its wavelength. Depth of tissue
penetration is directly related to wavelength and inversely related to frequency. Shorter wavelengths
are associated with more scattering and attenuation. Consequently, image resolution improves as
transducer frequency increases at the expense of tissue penetration. Higher frequencies should be
utilized to image areas of interest close to the transducer and lower frequency transducers with greater
tissue penetration are better for imaging more distal structures.
B-Color: The 2-D image composed of echo amplitudes mapped in different shades of gray,
different colors or even hues of colors. Although <B-COLOR> maps do not change ultrasound
information, they can improve individualized perception of the information.

1800.

Left/Right: Changes the left/right (<L/R>) orientation of the displayed image by rotating it
Up/Down: Inverts the displayed image by pressing the <U/D> button.

Freeze/Run & Cine : <FREEZE/RUN> stops the real time video display or Doppler image at
the current frame. The Extended Freeze function allows the operator to scroll through the memory by
turning the <FREEZE/RUN> wheel either counterclockwise to display earlier frames or clockwise to
display later frames. Pressing the <FREEZE/RUN> wheel again returns the operator to real-time
imaging.
DopplerEchocardiography
Doppler echocardiography is used to interrogate blood flow characteristics (velocity, direction) by
comparing the ultrasound frequency emitted to the ultrasound frequency received by the transducer (Doppler
Shift) according to the Doppler Equation:
V = c (Fs Ft) / 2 Ft (cos )
v = velocity
= intercept angle between blood flow and ultrasound beam
Fs = frequency received Ft = frequency transmitted
c = speed of sound in blood (1540 m/sec)
Blood flow velocities can be displayed as a spectral wave form analysis of velocities (displayed as gray pixels on
the vertical axis) over time (horizontal axis) with Pulse Wave or Continuous Wave Doppler. By convention,
positive Doppler Shift (towards the transducer) is displayed above the baseline, while a negative Doppler Shift
(away from the transducer) is displayed below the baseline. Alternatively, blood flow velocities can be displayed
in color with Color Flow Doppler, analogous to a non-invasive real time angiogram.
Pulse Wave Doppler (PWD): Pressing the <PW> activates Pulse Wave Doppler and allows the
operator to sample blood flow velocities from a specific cardiac depth by manipulating the <CURSOR> with
the track ball to orient the ultrasound beam displayed from the top to bottom of the screen, while simultaneously
viewing the 2-D image in real time. The Nyquist Limit (1/2 PRF) limits the maximum detectable velocity.
When using Pulse Wave Doppler, the transducer must wait for a returning ultrasound signal before the next
pulse of ultrasound waves can be transmitted. Although this allows for measuring velocities at a specific
depth, very high blood flow velocities cannot be measured. Increases in <DEPTH> decrease the PRF and the
Nyquist Limit to a certain degree. Velocities that exceed the Nyquist Limit appear on the opposite side of the
zero baseline and are termed aliasing .

Gate: Adjusts the <GATE> length by increasing or decreasing the two small horizontal lines,
that are perpendicular the PW ultrasound beam. The <GATE> length limits the size of the pulse wave
sample volume to focus on velocities only in the area of interest.
Angle: Adjusting the <ANGLE> allows the operator to correct for the incident angle () of the
ultrasound beam when the line of interrogation is not parallel to the direction blood flow at the site of
interest. The true velocity of blood flow will differ significantly from the actual velocity if these are not
parallel. According to the Doppler Equation, the cosine of the angle will only be one if the angle is 00 or
1800. An angle of 900 gives a cosine angle value of zero. Excessive error is introduced if the angle of
intercept exceeds 200 and is not corrected.
Baseline: Adjusting the <BASELINE> moves the zero velocity line on the spectral display
either up or down and helps to keep velocities within the limit of the scale and avoid aliasing.
Scale: Adjusts the <SCALE> to increase (up) or decrease the range of (down) velocities to
prevent aliasing and optimize the Doppler signal. High Pulse Repetition Frequency (HPRF) will be
activated at the PWD scale limit and allows for increased velocity detection at depth and localization of
flow. HPRF generates multiple sample volumes displayed with smaller secondary gates in addition to
the standard gate size of the primary sample volume. The maximum velocities that can be measured,
however, will still eventually be limited with PWD by the Nyquist Limit in comparison to CWD.
Update: Pressing the <UPDATE> button limits the amount of time the real time, 2-D image is
simultaneously displayed, thereby allowing the operator to reposition the <CURSOR> if it should move
relative to the site of interest while still maintaining the highest quality Doppler profile. The best quality
Doppler signal is generated with the 2-D image frozen without <UPDATING>.
Gain: <D GAIN> attenuates or augments sensitivity to the Doppler signal. Increasing the <D
GAIN> will increase the intensity of the signal but may also increase noise and potentially create
artifact.
Processing: <FILTER> can eliminate low frequency Doppler signals (slow moving cardiac
structure) by setting a minimum frequency that will be analyzed. <COMPRESS> adjusts the range of
gray shades of the Doppler spectrum.
Continuous Wave Doppler (CWD): Pressing the <CW> button on the console activates the CWD
mode. In similar fashion to PWD, a Doppler spectral display of velocity vs. time will be displayed
simultaneously with an image designating the cursor line of the CWD ultrasound beam, superimposed on a real
time 2-D image. The trackball can be used to manipulate the beam along the desired optimal pathway for
measuring the flow velocities of interest. Continuous Wave Doppler has the advantage over PWD of allowing
the operator to sample continuously along the entire cursor line enabling the measurement of very high
maximum velocities without aliasing (no Nyquist Limit), but sacrificing the ability to interrogate at a specific
site (range ambiguity). Optimizing the signal resolution and image enhancement is otherwise similar to PWD.
Color Flow Doppler (CFD): Pressing <D COLOR> or <DCFI> (Doppler Color Flow Imaging)
activates Color Flow Doppler such that blood flow velocities are displayed in color superimposed on the 2-D
image rather than a spectral display. The technology of CFD is based upon pulsed wave principles using
multiple sample volumes along each sample line. By convention, red color indicates flow toward the transducer
and blue color indicates blood flow away from the transducer. The shade of color (maximum detectable
frequency shift or velocity) is set by the Nyquist Limit (1/2 PRF). The presence of a mosaic color pattern
usually indicates rapidly changing velocities and/or direction of flow. The velocity scale is displayed on the
video screen including the range of velocities beyond which aliasing will occur. Frequency and depth affect the
PRF and therefore the maximum detectable velocity. Lowering the frequency of the transducer increases the
maximum flow velocities that can be measured before aliasing.
When CFD is activated, a sector appears on the screen representing the area of
interrogation. The size (length / width) and position of this window can be manipulated with the trackball. The
larger the sector selected for CFD analysis, the slower the image will appear. Since the ultrasound computer

requires time to process and display CFD and 2-D imaging simultaneously, the number of times the image can
be scanned per minute is decreased (decreased frame rate). Minimizing the size of the sector increases the frame
rate and the maximum measurable flow velocity before aliasing. The color <GAIN> should be decreased just
until color within tissues imaged by 2-D and the speckling or noise in the color flow segment are eliminated.
<SCALE> and <BASELINE> functions are comparable to PWD and CWD.
Data Acquisition and Analysis
Once a real time image is frozen (<FREEZE>), linear, circumferential, area measurements and
calculations can be made:
Calipers: Pressing the <CALIPER> or <POINT> button displays a cross-hair point on the screen
which can be moved with the track ball. Pressing the <ADD CALIPER> or <POINT> button a second time
adds another cross-hair point which can be used with the initial point to make linear measurements between the
cross-hairs, and are displayed on the screen in centimeters. Pressing either button again removes the calipers.
Trace: Pressing the <TRACE> button allows the operator to trace the outline of an area of interest
using the trackball to move the cursor back to the starting point. The circumference and enclosed area are
displayed on the video screen in centimeters.
Calculations: Pressing the <CALC> button allows the operator to make a number of measurement and
computations in the 2-D, M-mode and spectral Doppler platforms pertaining to ventricular function (systolic and
diastolic), cardiac performance, hemodynamics, and cardiac/great vessel structural dimensions. Pressing
<REPORT> displays the stored data in a summarized worksheet of averaged values that allows for editing.
Options: Most manufacturers have additional software packages that allow for more sophisticated data
processing and analysis for a more advanced assessment of hemodynamics and cardiac function (i.e., acoustic
quantification, color kinesis, harmonic imaging, 3D imaging etc.)
Archiving and Storage
All ultrasound machines have a VCR that can be used to record an echocardiographic exam for
immediate review or storage. Most machines also have digital image system capabilities to store static or
dynamic images.
References
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Hedrick WR, Hykes DL, Starchman DE (eds.). Ultrasound Physics and Instrumentation (3rd ed.).
St.Louis, Mosby, 1995.
Otto CM, Pearlman AS: Principles of Echocardiographic Image Acquisition and Doppler Analysis. In
Otto CM, Pearlman AS (eds.): Textbook of Clinical Echocardiography (1st ed). Philadelphia, W.B.
Saunders, 1995.
Weyman, AE (ed.). Principles and Practice of Echocardiography (2nd ed.). Philadelphia, Lea & Febiger,
1994.
Hewlett Packard: HP Sonos 5500 Imaging System Basics (1st ed.). Andover, MA, 1997.
Acuson Corporation: Acuson Sequoia C256 Echocardiography System Cardiology Applications
Manual (1st ed.) Mountain View, CA, 1996