571165

research-article2015
JDMXXX10.1177/8756479315571165Journal of Diagnostic Medical SonographyMayer

Literature Review
Journal of Diagnostic Medical Sonography

At the Heart of the Matter: An

2015, Vol. 31(4) 221­–232
© The Author(s) 2015
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DOI: 10.1177/8756479315571165

for the Non–Cardiac Sonographer jdms.sagepub.com

Pamela Mayer, BSDMS, RDMS1

Abstract
Echocardiography is an excellent method for evaluating cardiac morphology and dynamic function. It has a long
history of innovative thinking mixed with some degree of serendipity. Its early applications were as a tool to evaluate
the mitral valve, left ventricular characteristics, and pericardial effusion. Today it has evolved into a robust modality
that allows for a very wide range cardiac interrogation, able to evaluate the valves, chambers, myocardium, and
pericardium. The practice of echocardiography also is often separate from that of general or vascular sonography.
The objective of this article is to provide the non–cardiac sonographer with an overview and appreciation of the basic
principles and practices of echocardiography. It is not meant as a guide to scanning but rather, as a vehicle to spark the
interest and imagination of the reader.

Keywords
echocardiography, 2D echo, 3D echo, contrast echocardiography, speckle tracking

Introduction heart disease was pioneered by cardiologist Inge Edler

Echocardiography provides the ability to evaluate the
morphology and function of the heart and can yield valu-
able information regarding the cardiac status of the
patient. Prior to the development of echocardiography,
cardiac catheterization was the primary method of visual-
ization of the heart. Interest in echocardiography in the
1950s led to the use of this noninvasive technique as the
first-line study of choice for the evaluation of cardiac
anatomy and pathology.1 Modern echocardiography is
able to evaluate the valves, chambers, myocardium, and
pericardium of the heart in order to detect a wide range of
pathologies utilizing M-mode, two-dimensional (2D),
and color and spectral Doppler.
As new technology emerges, the ability of echocardiog-
raphy to detect, quantify, and treat cardiac pathology and
dysfunction will continue to advance. Present and future
advances in acquisition methodologies such as three-
dimensional instantaneous full volume imaging, speckle
tracking, contrast echocardiography, and miniaturization
of scanning equipment and intracardiac probes present
exciting new paths for the evolution of echocardiography.
Historical Overview
The history of echocardiography is an interesting one
filled with innovation, ingenuity, and serendipity.1 The
use of sonography as a diagnostic tool in the detection of
and physicist Carl Helmuth Hertz. Elder was disap-
pointed in the ability to detect mitral valve disease using
cardiac catheterization techniques. He imagined the pos-
sibility of a noninvasive alternative. In the early 1950s, he
was referred to Hertz, whose father was the director of
Siemens Research Laboratory. Through him, he discov-
ered that Siemens had developed a reflectoscope that was
being used for nondestructive metal testing at a local
shipyard. Hertz made a visit to the shipyard to see the
equipment. During his visit, he placed the transducer on
his chest. The first A-mode display of the heart was made
that day.1 Edler and Hertz were able to obtain a modified
reflectoscope from Siemens, and they went on to develop
M-mode capabilities.
It wouldn’t be until the 1960s that interest in echocar-
diography came to the United States where cardiologist
Harvey Feigenbaum would emerge as one of the leading
proponents for the use of echocardiography. The term
echocardiography can be attributed to him. Feigenbaum’s
interest in echocardiography began in 1963 and paralleled
1
Department of Radiology, Flagstaff Medical Center, Flagstaff, AZ,
USA
Corresponding Author:
Pamela Mayer, BSDMS, RDMS, Department of Radiology, Flagstaff
Medical Center, 1200 N. Beaver Street, Flagstaff, AZ 86001, USA.
Email: mayerpa@gmail.com
222
that of Edler, a response to frustration with cardiac cath-
eterization techniques for measuring cardiac volumes. He
reported scanning through a journal one day and coming
across an advertisement for a piece of ultrasound equip-
ment that claimed to be able to measure cardiac volumes.
Feigenbaum visited a booth demonstrating the equipment
at a convention and soon found that the equipment was
not particularly useful in determining volume measure-
ments. However, when he put the transducer to his chest,
much as Hertz had done ten years prior, he realized that
he was seeing motion from the back wall of his left ven-
tricle.1 This realization ignited his interest in
echocardiography.
In addition to introducing echocardiography’s utility
as a method of measuring ventricular dimensions and
detecting pericardial effusions, Feigenbaum is credited
with advancing standardization and education within the
discipline. He established educational programs to train
not only physicians but also non-physician operators. He
was the first to hire a non-physician to perform echocar-
diography, and it was his opinion that a productive, dedi-
cated echocardiographer could produce more reliable
results than the occasional physician operator. The physi-
cian would then interpret the resulting study. In fact, he
asserted that “many sonographers become extremely
skilled and are almost artists as they create their ultra-
sonic pictures.”1
The next major advance in echocardiography was
two-dimensional imaging. When a mechanical sector
scanner was finally developed, two-dimensional echocar-
diography (2DE) in the clinical environment became fea-
sible. With the addition of spectral Doppler and color
Doppler technology, modern echocardiography was born.
Cardiac Anatomy Review
Understanding the principles of echocardiography must
begin with at least a brief understanding of basic cardiac
anatomy. The heart has an oblique lie within the thoracic
cavity, with two-thirds of its mass residing to the left of
the median plane. The apex is formed by the left ventricle
at the level of the fifth intercostal space. The atria are the
major components of the base of the heart, which projects
superiorly, posteriorly, and medial to the apex. The heart
has three surfaces: the base or posterior surface, the ante-
rior sternocostal surface, and the diaphragmatic surface.
It also has four borders: the right, left, inferior, and supe-
rior borders. The heart wall consists of three layers. The
outermost of these layers is the epicardium, which is also
the visceral layer of the pericardium. The cardiac muscle
layer is the myocardium. The endocardium is the inner-
most endothelial lining. The heart also consists of four
chambers and valves, which along with their associated
vessels are depicted in Figure 1.
Journal of Diagnostic Medical Sonography 31(4)
The right atrium receives de-oxygenated blood from
systemic and coronary veins via the inferior vena cava,
superior vena cava, and coronary sinus. The blood then
enters the right ventricle and is pumped into the pulmo-
nary trunk for oxygenation during transit through the
lungs. The left atrium, which forms most of the base of
the heart, receives oxygenated blood from the right and
left pulmonary veins. The left atrium empties into the left
ventricle, which pumps the oxygenated blood into the
ascending aorta. The ventricles are separated by an inter-
ventricular septum.
There are four heart valves that consist of fibrous tis-
sue with an endothelial covering. The valves consist of
leaflets or cusps that allow them to open and close. There
are two basic types of valves: semilunar and atrioventric-
ular. The semilunar valves are found between the ventri-
cles and the great vessels, the aortic valve between the
left ventricle and the aorta, and the pulmonic valve
between the right ventricle and the pulmonary trunk. The
semilunar valves have three cusps that are cup shaped and
open during ventricular contraction. They close during
ventricular relaxation in order to prevent reflux of blood
into the ventricles.2,3
The atrioventricular valves allow blood to flow from
the atria to the ventricles. The mitral valve has two cusps
and communicates between the left atrium and ventricle.
The tricuspid valve has three cusps and communicates
between the right atrium and ventricle. The walls of the
atrioventricular valves are thinner than those of the semi-
lunar valves, and they readily move in the direction of
blood flow. The atrioventricular valves are attached to the
ventricular walls by chordae tendineae, cordlike tendons,
which attach to the papillary muscles that project from
the ventricular walls.3 They have a fibrous ring, called an
annulus, that encircles the opening and provides stability.
Ventricular contraction forces the valves closed to pre-
vent reflux of blood into the atria.2
Blood is supplied to the heart muscle itself by the coro-
nary arteries. The right and left coronary arteries arise
from the ascending aorta. They then branch to provide
blood supply to the entire cardiac muscle. Coronary
venous drainage is achieved primarily through the coro-
nary sinus, a thin-walled venous channel on the posterior
surface of the heart that empties into the right atrium.2 The
pericardial sac encloses the heart muscle. It is comprised
of two layers, the visceral and parietal layers. The visceral
layer forms the outer layer of the cardiac wall and is alter-
nately referred to as the epicardium. A small amount of
serous fluid lubricates the space between the two layers.
Echocardiography Basics
Traditional echocardiography incorporates a variety of
acquisition methodologies, including M-mode, 2D
Mayer
Figure 1. Artist’s drawing of the human heart showing the four chambers and their associated valves, as well as the major inflow
and outflow vessels. (Used with paid permission from Shutterstock.com).
echo, pulsed and continuous wave Doppler, and color
flow Doppler. M-mode continuously interrogates along
a single scan line and is useful for timing cardiac
events and providing dimensional measurements. The
2D echo evaluates cardiac anatomy, real-time ventric-
ular and valvular motion, and is used to position the
M-mode and spectral Doppler cursors. Spectral
Doppler provides velocity measurements. Pulsed wave
Doppler primarily evaluates valvular flow patterns,
left ventricular diastolic function, stroke volume, and
cardiac output. Continuous wave Doppler, which does
not suffer from the aliasing artifact, is useful in high
flow velocity situations, such as evaluation for valvu-
lar stenosis and regurgitation, as well as providing
information on the velocity of flow in shunts. Color
flow Doppler superimposes a color map of the pres-
ence and direction of flow over a 2D gray-scale image
and provides a rapid, qualitative means of detecting
regurgitation.4
223
Transthoracic Echocardiography
The typical transthoracic echocardiogram is obtained
with the patient in either a supine or left lateral decubitus
position. The echocardiographer may scan the patient
using either the left or right hand, depending on environ-
mental ergonomics or echocardiographer preference. It is
advantageous for the echocardiographer to gain experi-
ence with both approaches so as to minimize the potential
for repetitive stress injuries.5
Scanning Windows and Views
There are several scanning positions, or windows, that
are helpful in obtaining a complete transthoracic echocar-
diographic evaluation of the heart: the left parasternal,
apical, subcostal, and suprasternal notch (Figure 2). The
right parasternal position, though not a part of the normal
routine echocardiogram, may also be used. Several views
224
Figure 2. The basic scanning windows for transthoracic
echocardiography. (Used with paid permission from
Shutterstock.com).
are utilized in the course of a typical examination in order
to visualize structures within the heart, as shown in Table
1 and in Figures 3, 4, and 5.
Transesophageal Echocardiography
Transesophageal echocardiography (TEE) is an invasive
procedure that involves inserting a flexible echocardiog-
raphy probe into the esophagus. It has the advantage of an
anatomically closer visualization of the heart, which
allows better resolution through the use of higher probe
frequencies, with less artifact interference. TEE also pro-
vides visualization of cardiac structures that are not
accessible by the transthoracic method due to their poste-
rior location and provides a superior method for the eval-
uation of cardiac tumors and thrombi. Its disadvantage is
its invasive nature, which carries a small potential risk. It
also may be limited in patients with dysphagia, esopha-
geal disease, cervical instability, and severe pulmonary
disease.
Cardiac Pathology
Valvular Diseases
Evaluation of the heart valves, specifically the mitral
valve, was one of the earliest applications of echocar-
diography. The mitral valve was historically imaged
using M-mode to record valve cusp motion and to evalu-
ate how the valve functioned over a period of time. Today,
2DE is considered the reference method for evaluation of
mitral valve abnormalities, which may include stenosis,
regurgitation, and/or prolapse. Advances in technology
and technique have expanded the ability of echocardiog-
raphy to include evaluation of all four valves by M-mode,
Journal of Diagnostic Medical Sonography 31(4)
2DE, and Doppler. The most common cause of valvular
dysfunction is a history of rheumatic heart disease.5
Stenosis can occur in any of the four valves to a greater
or lesser degree, and it generally is a result of a thickening
of the valve cusps that restricts their ability to open fully.
While M-mode can provide information regarding reduc-
tion in valvular motion, 2DE allows for direct visualiza-
tion of the orifice and the associated valve anatomy. Color
and spectral Doppler have proven to be the most useful
methods of evaluation of valvular stenosis, as they can
provide both flow direction and pressure gradient infor-
mation and allow quantification of the area of stenosis.6
In cases of mitral and tricuspid valve stenosis, the thin
leaflet tips typically become stiff and may calcify. Mitral
stenosis is far more common a condition than tricuspid
stenosis.7–9 When tricuspid stenosis does occur, it is usu-
ally in conjunction with mitral stenosis.10–12
The aortic and pulmonary valves have thicker leaflets
than the mitral and tricuspid valves, and stenosis in these
valves may be at any one of three levels, valvular, subval-
vular, or supravalvular, with the most common location
the valvular level.5 Both aortic and pulmonary stenosis
may be congenital or acquired. Pulmonary stenosis is
more often congenital, whereas aortic stenosis is often
acquired.13 Aortic stenosis is most commonly the result of
rheumatic heart disease, age-related degenerative
changes, and congenital bicuspid valve.14–16
Regurgitation is a reflux of blood flow through the
valve during the cardiac cycle. Mitral and tricuspid regur-
gitation occur during systole and result in backflow from
the corresponding ventricle to the atrium. It may be caused
by damage to the valves and supporting structures due to
rheumatic disease and age-related deterioration. It may
also result from rupture of the papillary muscle or chordae
tendineae.5 Tricuspid regurgitation is a relatively common
finding in adult patients and usually results from right ven-
tricular dilation. Continuous wave (CW) Doppler velocity
measurements of tricuspid regurgitation are useful in the
estimation of pulmonary artery systolic pressure.17–20
Aortic and pulmonary regurgitation occur during dias-
tole and result in a backflow of blood from the great ves-
sels into the ventricles (Figure 6). It is frequently caused
by abnormalities of the aorta or the pulmonary artery. It
may also be caused by leaflet abnormalities. M-mode and
2DE are both effective methods for evaluating the aortic
valve for regurgitation but cannot directly assess pulmo-
nary regurgitation. Doppler remains the method of choice
for definitive diagnosis of pulmonary regurgitation.21–26
Improper or abnormal valve closure, or prolapse,
occurs most commonly in the mitral valve. The systolic
protrusion of one or both of the valve leaflets into the left
atrium secondary to mitral valve prolapse may be mild or
it may be severe enough to cause regurgitation during
systole. It is a common condition that affects up to 5% of
Mayer 225

Table 1. Standard Transthoracic Echocardiographic Anatomic Windows and the Cardiac Data Derived From Each (adapted
from Kaddoura4 and Armstrong and Ryan5).

Views Two-Dimensional (images) Doppler (evaluates and assesses )

Parasternal
Long-axis Base to apex, LV MR, AR, VSD
Long-axis, medial angle RV inflow and outflow RV inflow, TR
Short-axis, basal Level of AV AR, TR, PS, PR, VSD
Short-axis, mitral valve Level of MV MR
Short-axis, papillary muscles Papillary muscles
Short-axis apical LV apex
Apical
Four-chamber Four cardiac chambers MI, TI, MR, TR
Two-chamber Left atrium/ventricle MR, AR
Long-axis Left atrium/ventricle, AV, Asc Ao MR, AR
Five-chamber Four chambers with aortic valve LV outflow, AR
Subcostal
Four-chamber Four cardiac chambers RV inflow, TR, ASD
Short-axis, basal Interatrial septum, IVC, Abd Ao TR, Pulmonary flow, PR, IVC
Short-axis mid-ventricular Papillary muscles
Suprasternal
Long-axis Aortic arch Asc/Desc aortic flow
Short-axis Aortic arch

Abbreviations: Abd, abdominal; Ao, aorta; AR, aortic regurgitation; Asc, ascending; ASD, atrial septal defect; AV, aortic valve; Desc, descending;
IVC, inferior vena cava; LV, left ventricle; MR, mitral regurgitation; MV, mitral valve; PR, pulmonary trunk regurgitation; PS, pulmonary trunk
stenosis; RV, right ventricle; TI, tricuspid insufficiency; TR, tricuspid regurgitation; VSD, ventricular septal defect.

Figure 3. Gray-scale echocardiographic image of the heart

taken using the parasternal long-axis view, showing both the
left (LV) and right (RV) ventricles, the left atrium (LA), and
the aortic outflow tract (AO).
the population4 and may be identified by 2DE when either
of the leaflets protrudes above the level of the mitral
annulus during systole.27–30
Chamber Size and Function
The cardiac chambers are examined during a routine trans-
thoracic echocardiogram for both function and morphology.
Figure 4. Gray-scale echocardiographic image of the heart
taken at the approximate midlevel of the left ventricle
(LV) using the parasternal short-axis view, showing the
anterolateral (AM) and posteromedial (PM) papillary muscles
as well.
The left ventricle, in particular, is measured both in diameter
and volume to allow the calculation of functional informa-
tion such as stroke volume and ejection fraction. These are
clinically relevant particularly when ischemic changes sec-
ondary to myocardial infarct are suspected.31–33 The left
atrium can offer important information relevant to several
226
Figure 5. Gray-scale echocardiographic image of the heart using
the apical four-chamber view showing all four chambers. LA, left
atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
Figure 6. Gray-scale and color Doppler echocardiographic
image of the heart taken using the parasternal long-axis view,
showing reflux flow secondary to aortic insufficiency in the
aortic outflow tract (AO) at the level of the aortic valve.
disease states such as dilation, thrombus, and diastolic
dysfunction.34–37 The right atrium may become dilated in
the case of right ventricular pressure and volume over-
load.38,39 The right ventricle is not usually well seen on
echocardiography due to its location behind the sternum.
It can, however, be grossly measured and a visual com-
parison made with the left ventricle.40,41 The normal right
ventricle should be approximately two-thirds the size of
the normal left ventricle. The interatrial septum should be
evaluated for any defects,42 particularly a significant pat-
ent foramen ovale (PFO). PFO is common, occurring in
25% to 30% of adults, though only a small fraction of
these are clinically significant.5 The interventricular sep-
tum should also be evaluated for ventricular septal defects
or rupture.43–45
Journal of Diagnostic Medical Sonography 31(4)
Figure 7. Gray-scale echocardiographic image of the heart
taken using the parasternal long-axis view showing thickening
of the muscular layers of the left ventricular (LV) wall
characteristic of ventricular hypertrophy.
Figure 8. Gray-scale echocardiographic image of the heart
taken using the parasternal short-axis image view showing
concentric thickening of the left ventricular wall characteristic
of ventricular hypertrophy.
Cardiomyopathy
Cardiomyopathy is a broad term referring to a range of
cardiac muscle abnormalities that may arise secondarily
from etiologies outside the heart. There are three main cat-
egories of cardiomyopathies: hypertrophic, dilated, and
restrictive.5 Hypertrophic cardiomyopathy may be acquired
or genetic and obstructive or nonobstructive.46,47 In the
case of genetic etiology, several cardiac protein mutations
have been identified. In either type, the typical findings
include a localized thickening of the ventricular wall, a
decreased ventricular cavity size, and increased ventricular
stiffness (Figures 7 and 8). Hypertrophy may cause
obstruction, particularly if it occurs in the septal region.
Doppler is useful in determining if the hypertrophy is
Mayer
Figure 9. Colorized gray-scale echocardiographic image
of the heart using the apical four-chamber view showing a
thrombus in the apex of the left ventricle (arrow).
obstructive or not. Dilated, or congestive, cardiomyopa-
thy is the dilatation of the cardiac chambers. The left ven-
tricle is particularly affected. It causes poor contractility of
the left ventricle and a resultant low cardiac output.48,49
Valvular regurgitation is common, and a potential for
thrombus formation exists (Figure 9). Restrictive cardio-
myopathy is also called infiltrative cardiomyopathy. It is
characterized by increased stiffness or the inability of the
cardiac muscle to relax. The diastolic function of one or
both ventricles is abnormal. There may also be associated
atrial dilatation due to increased ventricular pressure.50–52
Pericardium
The pericardium, the lining that surrounds the heart, can
also become diseased and cause complications. The three
major categories of pericardial complications include
pericardial effusion, constrictive pericarditis, and cardiac
tamponade.5,53,54 Pericardial effusion is the accumulation
of fluid between the layers of the pericardium (Figure
10). Its evaluation was one of the first clinical applica-
tions of echocardiography. It may be secondary to an
inflammatory or an infectious process. It is possible to
detect an effusion with M-mode, as was originally done,
but it is much better assessed with 2DE.55,56
Constrictive pericarditis is a condition in which the
pericardium becomes rigid and may even become calci-
fied.50,51,57 It may be the result of disease or injury, or it
may have an idiopathic origin. As the name would imply,
it restricts ventricular movement, limiting expansion, and
filling of the ventricles. Doppler can detect abnormal
227
Figure 10. Gray-scale echocardiographic image of the heart
showing fluid between the pericardium and myocardium
(pericardial effusion) causing extrinsic compression of the
right ventricle.
flow patterns of the mitral valve as a result of abnormal
diastolic ventricular filling.50,51
Cardiac tamponade results from external pressure on
the heart that is significant enough to decrease cardiac
function. Even small effusions may cause tamponade if
they occur suddenly, as the pericardial sac may not have
time to adjust and stretch to accommodate the excess
fluid.58 Tamponade is an emergency situation that may
require the performance of therapeutic echocardio-
graphic-guided pericardiocentesis to relieve the fluid
pressure.59–61
Stress Echocardiography
Stress echocardiography provides information about the
effects of exercise on the heart and can detect changes in
morphology and function of the stressed heart as com-
pared with the resting heart. Some ischemic regional wall
motion and thickness abnormalities may only become
apparent when the heart is stressed.4,5,62 The physiologic
stress may be induced chemically or by physical exercise
by the patient. Stress echocardiography may be particu-
larly helpful in women with complaints of chest pain, as
ECG stress testing alone has been shown to be less reli-
able in this demographic.63–65
Current Trends and Future
Advances
Three-Dimensional Echocardiography
Until very recently, three-dimensional echocardiography
(3DE) systems depended on time-consuming and cum-
bersome reconstruction of 2DE images that had to be syn-
chronized with the electrocardiogram and respiration.
Not surprisingly, it was not a widely popular acquisition
228
Figure 11. Reconstructed colorized three-dimensional
echocardiographic image of the left ventricular showing an
apical thrombus (arrow).
method and was used primarily in research facilities.
Advances in transducer and software technology have
allowed for real-time acquisition of 3D images over sev-
eral cardiac cycles. Automated reconstruction software
makes the images available for offline analysis (Figure 11).
Even with these advances, however, this method is still
only useful as an adjunct to 2DE and does not replace it.
With the development of instantaneous full-volume
echocardiography, acquisition can now be obtained in a
single heartbeat and analyzed in real time.66 Instantaneous
full-volume imaging has overcome some of the temporal
resolution issues present with earlier 3DE methods. It has
been successful in accurately identifying valvular pathol-
ogies and can precisely recognize prolapsed segments. It
has also shown to be promising in the assessment of
mitral regurgitation and mitral stenosis. Conventional
2DE is considered to be the reference method for evaluat-
ing mitral stenosis, but it can lead to overestimation of the
mitral valve area. 3DE allows for the manipulation of
image orientation in real time, thus allowing for capture
of the most optimal plane from which to measure. The
3DE is able to image the aortic and tricuspid valves in
ways that allow better visualization of anatomic features.
The potential of 3DE to evaluate the origins of the coro-
nary arteries is also proving to be very promising.67
Speckle Tracking
Speckle tracking echocardiography (STE) quantifies myo-
cardial function by tracking the speckle pattern with the
2DE image. Imaging software merges the individual speck-
les into functional units called kernels. Each kernel has a
unique pattern of speckles, much like a fingerprint, that
makes them readily identifiable by the tracking software.
The elements of myocardial function that are analyzed
by STE are strain, strain rate, twisting, torsion, and
untwisting. Strain is the amount of deformation the
Journal of Diagnostic Medical Sonography 31(4)
myocardium undergoes during the cardiac cycle. Strain
rate is a measure of the rate of myocardial deformation, or
how quickly the myocardium deforms.68 Twisting is a
normal part of left ventricular systolic contraction and is
the reciprocal of the rotation of the apex and base during
systole. Torsion uses twisting values normalized with
respect to the base to apex distance. Twisting and untwist-
ing play an important role in diastolic filling.69
Image acquisition for STE is currently performed
using conventional 2DE and analyzing the information
offline. The images are acquired using a breath holding
technique and electrocardiographic (ECG) tracing.
Analysis is performed at dedicated workstations with
specific speckle tracking software. Potential clinical
applications for STE include the cardiac evaluation of
patients with hypertension, diabetes, coronary artery
disease, valvular heart disease, heart failure, cardiomy-
opathies, and as a follow-up to resynchronization ther-
apy. It may also prove to be useful in the evaluation of
heart transplantation, left atrial function, and chemo-
therapy-induced subclinical dysfunction.69 One future
advantage of STE is that it provides a method for evalu-
ating myocardial function in ways that were only previ-
ously possible by magnetic resonance imaging. New
technology is allowing it to be merged with three-
dimensional technology, which may yield even more
sophisticated data sets. As the acquisition and analytic
capabilities of STE improve, it may emerge as the most
advanced method for the evaluation of myocardial
function.69
Contrast Echocardiography
Echocardiography, while an excellent diagnostic tool,
does have technical limitations that result in suboptimal
imaging on some patients. Obesity and lung disease, for
instance, can significantly reduce the diagnostic quality
of the routine transthoracic echocardiogram.70 Contrast
echocardiography (CE) has been able to overcome some
of these limitations. Contrast agents used in echocardiog-
raphy consist of microbubbles made from a high molecu-
lar weight gas. The microbubbles, slightly smaller in size
than a red blood cell, are injected intravenously and freely
diffuse throughout the blood pool. They enhance visual-
ization of the left ventricular cavity and myometrium
because the microbubbles have highly echogenic sono-
graphic characteristics that differentiate them from the
surrounding tissue and red blood cells. An important fea-
ture of microbubble design is the encapsulating shell sur-
rounding the gas; it must be elastic enough to compress in
an ultrasound field and allow for resonant oscillation but
not be so stiff as to rupture too easily.71
CE allows improved visualization of the left ventricu-
lar endocardial borders (Figure 12), and this is the only
FDA-approved application thus far. It may also provide
Mayer
Figure 12. Contrast enhanced echocardiographic image
showing opacification of the left ventricle with good
visualization of the endocardial borders.
significant information regarding myocardial perfusion,
but the FDA has not yet approved it for that use in the
United States. It has proved useful for the presence or
exclusion of apical hypertrophic cardiomyopathy, left
ventricular thrombus, and complications of myocardial
infarction and can be used for both routine and stress
echocardiography.70,71
Certain limitations and safety concerns exist with the
use of CE. Ultrasound power settings play significantly
into these concerns. Cavitation, the interaction of ultra-
sound with gas, has long been a bioeffects consideration
for diagnostic ultrasound. The introduction of contrast for
echocardiography introduces gas containing bodies into
the circulation and raises additional concerns that cavita-
tion may result in damage to nearby cells.72 Since the risk
increases with increased power, the overall transmitted
ultrasound power should be significantly reduced so as to
control destruction of contrast microbubbles and to
reduce the risk of tissue heating and cavitation. A recent
prospective multicenter study of the contrast agent
Definity (Lantheus Medical Imaging, North Billerica,
Massachusetts, USA)70 and a registry review of both
Definity and Optison (GE Healthcare, Milwaukee,
Wisconsin, USA)73 have addressed this and other con-
cerns. These studies showed no serious adverse events
associated with contrast echocardiography.
Miniaturization
Miniaturization has had a huge impact on technology, and
echocardiography is no exception. Echocardiography
equipment 20 years ago was roughly the size of a refrig-
erator. Today’s fully functional echocardiography
machines can be as small as a laptop computer.74
Transesophageal echocardiography is used routinely
in operating rooms to monitor cardiac hemodynamics
229
during surgery, but until recently catheter size has been a
significant limitation to more widespread use. New
developments have led to probes that are approximately
the size of nasogastric catheters, and these transducers are
able to provide on-demand hemodynamic assessment for
the intensive care patient.75
Pocket-sized scanners that are the approximate size of
a smartphone have also come onto the market. These
scanners have full 2D and limited Doppler and color
Doppler capabilities. Images may be stored to a standard
SD card and uploaded to a computer for permanent stor-
age or printing. Echocardiography capabilities of pocket-
sized point-of-care scanners include bedside evaluation
for pericardial and pleural effusions as well as ventricular
and valvular function. It must be noted that appropriate
training for all potential users must accompany the avail-
ability of pocket scanner for them to reach their full
potential.76 It must also be understood that they are not
meant to replace conventional echocardiography but are
meant as a first-line evaluation and triage tool.77
Conclusion
Echocardiography has achieved significant advance-
ments since its beginnings as an M-mode tool to assess
mitral valve function and pericardial effusion. Sixty years
of technological advances and innovative design features
have made echocardiography an essential tool for the
evaluation of cardiac morphology and function. The addi-
tion of sophisticated signal acquisition methods such as
3DE, speckle tracking, and contrast echocardiography
have added new and exciting dimensions to the contribu-
tion that echocardiography can make to cardiology. The
extent of the ability of echocardiography to interrogate
the heart is still evolving today, and the promise of future
innovations will keep the technology in the forefront in
the battle against heart disease.
Acknowledgment
I would like to acknowledge Kene Osuno, RDCS, for his contri-
bution of the cardiac images used and his review of this article.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author received no financial support for the research,
authorship, and/or publication of this article.
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