Topics in Medicine and Surgery

Avian Echocardiography
Michael Pees, DrMedVet
Maria-Elisabeth Krautwald-Junghanns, ProfDrMedVet, Dipl. ECAMS

Abstract
Echocardiography in birds is a useful intravitam technique for morphological and
functional cardiac assessment, although the technical equipment has to be ad-
vanced to examine the avian heart. Probes with small coupling surfaces and
frequencies of at least 7.5 MHz are necessary, and ultrasound devices should be
able to produce at least 100 frames/s. A bipolar ECG is used to examine the heart
in endsystolic and enddiastolic stage. Two approaches for coupling the probe are
described. By using the ventromedian approach, two horizontal longitudinal views
present the chambers, the interventricular septum, and the valves of the heart.
Reference values for B-Mode and spectral Doppler are available for different
species, but experiences with Doppler examinations in diseased birds are still rare.
Common pathological echocardiographic findings in birds are hydropericardium,
hypertrophy and/or dilation of the right ventricle, and hypertrophy of the muscular
right atrioventricular valve. Copyright 2005 Elsevier Inc. All rights reserved.

Key words: Bird; heart; echocardiography; ultrasound; B-Mode; Doppler; cardiac

disease

D
ue to the technical progress over the last
years, echocardiography in birds has be-
come a valuable and important diagnostic
tool. It is safe and easy to perform and therefore
indicated in every bird with signs of cardiovascu-
lar disease, eg, abdominal distension, incoordina-
tion, or bluish discoloration of the (periorbital)
skin.
As in mammals, the great advantage of ultra-
sound in examining the bird’s heart is the presen-
tation of the inner structures and therefore the
possibility to assess both the morphological and
the functional status. However, due to anatomical
peculiarities of the avian heart, the protocol (stan-
dardized views) recommended for echocardiogra-
phy in mammals cannot be used in birds.1
M-Mode, a valuable tool for assessment of wall
thickness and contractility in mammals, is not
useful in birds, because the avian heart is only
visualized in longitudinal and semitransverse
views. To date, B-Mode (2-D-echocardiography)
in birds is an established examination technique,
and reference values have been reported for sev-
eral species. Recent studies prove the potential
value of Doppler as a reliable technique for the
assessment of cardiac blood flow in the avian pa-
tient. Systematic examinations and reference val-
ues using pulsed-wave-Spectral-Doppler are avail-
able for some species whereas the use of Color-
Doppler is only documented in some case reports.
From the Clinic for Birds and Reptiles, University of
Leipzig, An den Tierkliniken 17, 04103 Leipzig, Germany.
Address correspondence to: Michael Pees, Clinic for Birds
and Reptiles, University of Leipzig, An den Tierkliniken 17,
04103 Leipzig, Germany. E-mail: pees@vmf.uni-leipzig.de.
© 2005 Elsevier Inc. All rights reserved.
1055-937X/05/1401-00084$30.00
doi:10.1053/j.saep.2005.12.005

14 Seminars in Avian and Exotic Pet Medicine, Vol 14, No 1 ( January), 2005: pp 14 –21
Avian Echocardiography 15

● A minimum of 100 frames per second;

Figure 1. Bipolar ECG for triggering the cardiac stage. A metal
ball is soldered on an alligator clip (small image), which is
clipped on the basis of a feather to get contact between the ball
and the skin. Clip A is attached at the cranial end of the sternum
slightly on the right side, and clip B is attached at on the caudal
part of the sternum slightly on the left side following the mean
electrical axis of the heart (blue).
Technical Equipment
The high heart rate and the small size of the inner
structures of the avian heart make high demands
on the technical equipment. Ultrasound devices
for use in avian diagnostic should meet the fol-
lowing requirements:
● Electronic probe with small coupling surfaces
(microcurved, phased array) and a frequency
of 7.5 MHz or higher;
● Doppler function (spectral Doppler, Color
Doppler);
● Electrocardiography (ECG)-trigger function;
and
● Internal hard disc for storage of images and
motion loops, or the possibility to record on
video tape.
The high frame rate is necessary to get images
from defined cardiac stages as systole and dias-
tole. In birds with heart rates up to 600 beats per
minute, meaning 10 beats per second, a frame
rate of 100 images per second provides 10 images
per cardiac cycle.
The size of the probe is critical, especially in
small birds. Best results are obtained by using
scanners developed for human pediatric medi-
cine as well as for operative or gynecological use.
For birds up to 1000 g of body mass, a scanner
frequency of 7.5 MHz is recommended for proper

Table 1. Selected Measured and Calculated Values for the Assessment of Cardiac
Function in Birds (Mean ⴞ Standard Deviation).
Psittacus e. Amazona Cacatua diurnal
Parameter erithacus7 spp.7 spp.7 raptors*5 pigeons4
body mass [g] 493 ⫾ 55 353 ⫾ 42 426 ⫾ 162 720 ⫾ 197 434 ⫾ 52
left ventricle
length systole [mm] 22.5 ⫾ 1.9 21.1 ⫾ 2.3 19.0 ⫾ 1.3 14.7 ⫾ 2.8 17.9 ⫾ 1.0
length diastole [mm] 24.0 ⫾ 1.9 22.1 ⫾ 2.2 19.9 ⫾ 1.6 16.4 ⫾ 2.7 20.1 ⫾ 1.4
width systole [mm] 6.8 ⫾ 1.0 6.7 ⫾ 1.2 6.4 ⫾ 1.7 6.3 ⫾ 1.1 5.2 ⫾ 0.4
width diastole [mm] 8.6 ⫾ 1.0 8.4 ⫾ 1.0 8.3 ⫾ 1.5 7.7 ⫾ 1.2 7.4 ⫾ 0.6
width fractional shortening [%] 22.6 ⫾ 4.4 22.8 ⫾ 4.2 25.6 ⫾ 7.0 n.g. 27.2 ⫾ 4.5
right ventricle
length systole [mm] 9.2 ⫾ 1.4 9.4 ⫾ 1.8 10.3 ⫾ 1.2 12.7 ⫾ 2.7 n.g.
length diastole [mm] 11.5 ⫾ 1.9 10.3 ⫾ 1.3 11.3 ⫾ 2.3 13.9 ⫾ 2.5 9.9 ⫾ 0.8
width systole [mm] 2.8 ⫾ 0.9 3.1 ⫾ 0.7 2.3 ⫾ 0.0 2.1 ⫾ 0.6 n.g.
width diastole [mm] 4.8 ⫾ 1.1 5.2 ⫾ 1.3 3.5 ⫾ 0.5 2.5 ⫾ 0.8 4.0 ⫾ 0.5
width fractional shortening [%] 40.8 ⫾ 11.9 34.1 ⫾ 3.7 33.3 ⫾ 10.3 n.g. n.g.
IVS
thickness systole [mm] 2.9 ⫾ 0.5 2.2 ⫾ 0.1 1.9 ⫾ 0.3 1.9 ⫾ 0.6 3.8 ⫾ 0.1
thickness diastole [mm] 2.5 ⫾ 0.3 2.1 ⫾ 0.4 1.7 ⫾ 0.4 1.9 ⫾ 0.5 3.3 ⫾ 0.2
Values taken in ventromedian approach, horizontal view (pigeons parasternal approach,
longitudinal view) (IVS ⫽ interventricular septum, n.g. ⫽ not given)
*diurnal raptors including Buteo buteo, Accipiter nisus, Accipiter gentilis, Milvus milvus
16
Figure 2. Coupling of the transducer on the ventromedian ap-
proach using a normally featherless area (small image).
visualization of the cardiac structures. Higher fre-
quencies may be beneficial but lead to a decrease
in frame rate and maximum examination depth.
Although there is only limited experience with
the use of Doppler in birds, ultrasound devices
used for cardiology should provide both spectral
Doppler and color Doppler function: these tech-
niques will become more important in the future.
The trigger function is useful to correlate car-
diac images and measurements with certain stages
of the ECG, therefore being able to identify the
Figure 3. Visualization of the heart using the ventromedian
approach, vertical view. The liver serves as an acoustic window.
Pees and Krautwald-Junghanns
Figure 4. Using the ventromedian approach, the heart is pre-
sented in two views: the horizontal view (A) and the vertical view
(B). With the horizontal view, measurements (C) can be taken
from the following structures: left ventricle (1), right ventricle (2),
interventricular septum (3), left atrium (4), right atrium (5), and
aortic root (6).
corresponding cardiac stage (enddiastolic and
endsystolic). It is included in many ultrasound
devices designed for use in mammal cardiology,
but problems may arise due to the high heart rate
and the peculiarities of the avian ECG. In many
modern devices, the software can be adjusted to
solve these problems. Because the ECG only
serves for triggering the ultrasound image and
not for ECG assessment, it is sufficient to get a
bipolar lead following the mean electrical axis of
the bird.2,3
Finally, recording of digital motion loops or
video sequences is recommended because the as-
sessment and morphometry can be done after the
examination without stress for the bird.
How to Perform Echocardiography
in Birds
Preparation
Because the filled gastrointestinal tract may dis-
turb the penetration of the ultrasound waves,
birds should be fasted before examination. For
psittacines, 2 to 4 hours are recommended; pi-
geons should be fasted for 12 hours and raptors
up to 48 hours.2,4,5
The bipolar ECG can be derived as shown in
Fig 1, using alligator clips on the feathers and
ECG-gel.
For B-Mode examinations, anesthesia is recom-
mended only for stress-sensitive birds. Spectral
Doppler examinations should be done under gen-
eral anesthesia to reduce the influence of han-
dling and fixation to the blood velocity.6
Avian Echocardiography 17

Figure 5. B-Mode echocardiography in a healthy Gray parrot (Psittacus erithacus erithacus), ventromedian approach. Valves are visible
depending on the cardiac stage. A: vertical view, systole. B: horizontal view, diastole. C: horizontal view, systole (1, left ventricle; 1a,
left AV-valve; 2, left atrium; 3, liver; 4, sternum; 5, aorta; 5a, aortic valves; 6, right ventricle.).

Fixation, Approaches, and device or by an assistant (Fig 2). Especially in

Imaging Planes
To reduce the influence of the examination on
the cardiovascular system, the patient should be
held as upright as possible, either on a fixation
birds with clinical signs for cardiac disease, dorsal
recumbency may cause severe circulatory prob-
lems and therefore should be avoided. Commer-
cially available water-soluble acoustic gel is toler-
ated in birds without problems.
18
Figure 6. Coupling of the transducer using the parasternal
approach in a pigeon. The right leg is pulled forward, and the
transducer is directed craniomedially.
There are two approaches for echocardiogra-
phy in birds.1 There descriptions follow.
The Ventromedian Approach This is the main
approach. The transducer is coupled in the
median directly behind the sternum. In many
birds, the skin in this area is featherless,
and plucking of the feathers is not necessary
(Fig 2). The beam plane is directed craniodor-
sally, and the heart is visualized by using the
liver as an acoustic window (Fig 3). The heart
can be presented in two longitudinal views,
which are perpendicular to each other: the ver-
tical view (“two-chamber view”) and the hori-
zontal view (“four-chamber view”). The direc-
tion of the transducer is adjusted until the max-
imum extent of the ventricles is achieved (Figs
4 and 5).
The Parasternal Approach This additional
approach is usable in birds with sufficient
space between the last rib and the pelvic
bones, eg, pigeons and some raptor species.
The scanner is coupled on the right side
with the leg pulled either backwards or for-
wards and the beam plane is directed cranio-
medially (Fig 6). This approach shows the
heart in semitransverse views and may be help-
ful for the examination of the valves and the
vessels.
Pees and Krautwald-Junghanns
Morphological and
Functional Assessment
B-Mode (2-D-Echocardiography)
The size of the chambers, the relation between
both ventricles, the wall thickness of the interven-
tricular septum, and the contractility of the ven-
tricles can be assessed subjectively and by taking
measurements (Figs 4 and 5). Additionally, the
morphology and function of the left atrioventric-
ular (AV) valves, the aortic valves, and the right
muscular AV valve can be assessed depending on
the image quality. Signs of congestion (hydroperi-
cardium, ascites, and congestion of liver vessels)
are easy to recognize.
Measurements (Table 1) are taken from the
2-D-image following the “inner edge method”
(Fig 4).4,5,7,8 Besides the size, the contractility
(fractional shortening, FS) of the ventricles is of
special importance. It is calculated by using the
formula FS[%] ⫽ (diastolic value ⫺ systolic value)
⫻ 100/diastolic value. Due to the sickle moon
shape of the right ventricle in the avian heart, the
contractility of this chamber is much higher com-
pared with the left one.
Doppler Echocardiography
Spectral Doppler is used for determining the ve-
locity of the blood flow (inflow, outflow), which is
displayed as a two-dimensional graph against the
time (Fig 7). For measuring the velocity, the
blood flow should be as longitudinal as possible to
the direction of the ultrasound waves. For this
purpose, the ventromedian approach is ideal (Fig
Figure 7. Spectral Doppler echocardiography in a crow (Corvus
corone). The gate (A) is located in the area of the aortic root. The
velocity is shown against the time, indicating peaks of approx-
imately 1 m/s (B, maximum outflow during systole).
Avian Echocardiography 19

Figure 9. Color Doppler echocardiography in a crow (Corvus

Figure 8. Demonstration of blood flow directions and measure-
ment gates for spectral Doppler ultrasound, ventromedian ap-
proach, horizontal view (A, inflow into left ventricle; B, inflow into
right ventricle; C, aortic outflow.).
8). Reference values exist for the diastolic inflow
into the left and right ventricle and the systolic
outflow into the aorta (Table 2).9,10 The outflow
velocity is significantly higher compared with the
inflow velocities, which is caused by the shorter
ejection time and the smaller diameter of the
aortic root. Recent studies indicate a significant
influence of stress on the velocity of the blood
flow;11 therefore, it is recommended that the ex-
amination be done under isoflurane anesthesia.
Color Doppler shows the velocity of the blood
flow in colors overlaying the 2-D-image (Fig 9). It
corone), outflow during systole. Blood velocity is displayed in
blue indicating blood flowing away from the transducer into the
aortic root.
can be used for positioning of the gate for spec-
tral-Doppler-echocardiography but also has been
reported to be useful in detecting valvular insuf-
ficiencies12 and aneurysms.13 When using color
Doppler, the frame rate decreases considerably in
most ultrasound devices. This problem limits the
value of color Doppler in avian echocardiography
to date.
Pathological Findings
In many cases, ultrasonographic presentation of
the heart in birds with cardiac disease is much
easier compared with healthy birds, since organ

Table 2. Velocities of intracardial blood flow

(pulsed wave spectral Doppler, birds anaesthetized; n.g. ⴝ not given)
Psittacus Amazona Cacatua
Parameter erithacus10 spp.9 galerita10 Ara spp.10 Buteo buteo9 Falco spp.9
Diastolic 0.39 ⫾ 0.06 0.18 ⫾ 0.03 0.32 ⫾ 0.15 0.54 ⫾ 0.07 0.14 ⫾ 0.01 0.21 ⫾ 0.03
inflow
left
ventricle
[m/s]
Diastolic n.g. 0.22 ⫾ 0.05 n.g. n.g. 0.14 ⫾ 0.02 0.21 ⫾ 0.04
inflow
right
ventricle
[m/s]
Systolic 0.89 ⫾ 0.13 0.83 ⫾ 0.08 0.78 ⫾ 0.19 0.81 ⫾ 0.16 1.18 ⫾ 0.05 0.95 ⫾ 0.07
outflow
aortic
root
[m/s]
20
Figure 10. B-Mode echocardiography, yellow-crowned Amazon
(Amazona ochrocephala) with right-sided congestive heart fail-
ure, ventromedian approach. The left ventricle (1) is without
pathological finding, whereas the right ventricle (2) is strongly
hypertrophied and dilated. Also, the right AV-valve (2a) is hyper-
trophied. The anechoic area (3) between the heart and the
pericardium (4) indicates hydropericardium; ascites (5) is also
present.
enlargements (heart, liver) and fluid accumula-
tion in the thoracoabdominal cavity (due to con-
gestion) improves the image quality. In clinical
cases with abdominal distension, even larger
probes than recommended above are suitable for
examination.
The most frequent pathological echocardio-
graphic findings are hydropericardium and hy-
pertrophy/dilation of the right ventricle, both
indicating right-sided congestive heart fail-
ure.3,14,15 In these cases, the right ventricle often is
nearly as large as the left one; the walls are signif-
icantly thickened (Fig 10). In birds with hydro-
Figure 11. B-Mode echocardiography, gray parrot (Psittacus e.
erithacus) with hydropericardium (3), ventromedian approach (1,
left ventricle; 2, right ventricle; 4, liver tissue.).
Pees and Krautwald-Junghanns
Figure 12. B-Mode echocardiography, vinaceous parrot (Ama-
zona vinacea) with left-sided congestive heart failure, ventrome-
dian approach, vertical view. The left (1) and the right (2)
ventricle are dilated. The liver (3) is congested, and liver vessels
(4, cross section) are dilated. The left AV-valves appear thick-
ened (1a) (5, sternum.).
pericardium, an anechoic area is visible between
the heart and the pericardium (Figs 10 and 11).
Increase on blood pressure in the large circula-
tory cycle often leads to liver congestion (dilated
liver vessels visible) and to ascites (Figs 10 and
12). Hypertrophy of the right muscular AV valve is
often associated with hypertrophy of the right
ventricle (Fig 10).
Alterations of the left ventricle are seen less
frequently. They may be combined with thick-
ened atrioventricular valves, indicating valvular
damage and insufficiency (Fig 12). Left-sided con-
gestive heart failure normally is combined with
right-sided alterations due to congestion in the
small circulatory cycle.
Acknowledgements
This study was funded by the Deutsche For-
schungsgemeinschaft (DFG).
References
1. Krautwald-Junghanns ME, Schulz M, Hagner D, et
al: Transcoelomic two-dimensional echocardiog-
raphy in the avian patient. J Avian Med Surg
9:19-31, 1995
2. Krautwald-Junghanns ME, Pees M: Advances in
diagnosing cardiac diseases. Proc Assoc Avian Vet
Avian Specialty Advanced Program 2004:25-34
3. Pees M, Straub J, Krautwald-Junghanns ME:
Echokardiographische Untersuchungen bei
Psittaciformes, Teil 1: Durchführung und gat-
Avian Echocardiography
tungsspezifische Unterschiede. Tieraerztl Prax
31(K):126-31, 2003.
4. Schulz M: Morphologische und funktionelle
Messungen am Herzen von Brieftauben (Colum-
bia livia forma domestica) mit Hilfe der Schnitt-
bildechokardiographie. Doctoral thesis, Gies-
sen, 1995
5. Boskovic M, Krautwald-Junghanns ME, Failing K,
et al: Möglichkeiten und Grenzen echokar-
diographischer Untersuchungen bei Tag- und
Nachtgreifvögeln (Accipitriformes, Falconiformes,
Strigiformes). Tieraerztl Prax 27:334-341, 1999
6. Pees M, Straub J, Krautwald-Junghanns ME: Eval-
uating and treating the cardiovascular system, in
Harrison GJ, Lightfoot T (eds): The avian veteri-
nary compendium, vol 1. (in press)
7. Pees M, Straub J, Krautwald-Junghanns ME: Echo-
cardiographic examinations of 60 African grey
parrots and 30 other psittacine birds. Vet Rec
155:73-76, 2004
8. Wyatt HL, Heng MK, Meerbaum S: Cross-sec-
tional echocardiography I. Analysis of mathematic
models for quantifying mass of the left ventricles
in dogs. Circulation 60:1104-1113, 1979
9. Straub J, Pees M, Schumacher J, et al: Doppler-
21
echocardiography in birds. Proc Europ Assoc
Avian Vet 92-94, 2001
10. Carrani F, Gelli D, Salvadori M, et al: A prelimi-
nary echocardiographic initial approach to dia-
stolic and systolic function in medium and large
parrots. Eur Assoc Avian Vet 2003:145-149
11. Straub J, Forbes N, Pees M, et al: Effect of han-
dling-induced stress on the results of spectral
Doppler-echocardiography in falcons. Res Vet Sci
74:119-122, 2003
12. Rosenthal K, Stamoulis M: Diagnosis of congestive
heart failure in an indian hill mynah bird (Gracula
religiosa). J Assoc Avian Vet 1:27-30, 1993
13. Vink-Nooteboom M, Schoemaker NJ, Kik MJL, et
al: Clinical diagnosis of aneurysm of the right
coronary artery in a white cockatoo (Cacatua
alba). J Small Anim Pract 39:533-537, 1998
14. Pees M, Straub J, Krautwald-Junghanns ME: Insuf-
ficiency of the muscular right atrioventricular
valve in the heart of a blue-fronted amazon (Am-
azona aestiva aestiva). Vet Rec 148:540-543, 2001
15. Straub J, Pees M, Enders F, et al: Pericardiocen-
tesis and the use of enalapril in a fischer’s love-
bird. Vet Rec 152:24-26, 2003