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 Institut de Car diologie de
Montréal , Q u ébec, Canada

Toronto General Hospital

Ontario, Canada

Instit ut de C ardiolo gie de Montr éa l

and Hôpital du Sacré-Coeur de
Montréal, Québec, C anada

Research Center at th e Montr eal

Hea rt Ins t itute , Québec , Canada

Institut de C ardiologie d e
Montré al, Qu ébec, C anada
CRC Press
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 Dedication
This book is dedicated to:
My wife Denise Fréchette and my children Jean-Simon, Gabrielle, and Julien who
have supported me with love and patience (André Y Denault)
My parents, Patrick and Lena, and my brother Derek, who have always been
supportive (Annette Vegas)
Maude and Julien for their support and inspiration (Yoan Lamarche)
Michèle, Jean-Daniel and Pier-Luc (Jean-Claude Tardif)
Frédéric and Noémie (Pierre Couture)
And above all, our patients for whom we believe that knowledge in the use of
bedside ultrasound will improve their care.
The editors would like to thank sincerely Dora and Avrum Morrow
and the Richard I Kaufman Endowment Fund in Anesthesia and Critical Care.

Avrum Morrow Richard I Kaufman

List of contributors
Martin Albert, MD, FRCPC Associate Professor of Medicine,
Internist and Intensivist, Department of Medicine and Critical
Care, Hôpital du Sacré-Coeur de Montréal Research Center and
Intensivist, Department of Surgery, Institut de Cardiologie de
Montréal, Université de Montréal, Montréal, Québec, Canada
Christian Ayoub, MD, B.Pharm, FRCPC Clinical Assistant
Professor, Department of Cardiac Anesthesiology, Institut
de Cardiologie de Montréal, Department of Anesthesiology,
Maisonneuve-Rosemont Hospital, Université de Montréal,
Montréal, Québec, Canada
Mustapha Belaidi, MD Department of Cardiac Anesthesiology,
Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France
François M. Carrier, MD, FRCPC Clinical Assistant Professor,
Department of Anesthesiology and Division of Critical Care,
Department of Medicine, Centre Hospitalier de l’Université de
Montréal (CHUM), Université de Montréal, Montréal, Québec,
Canada
D. Catalina Casas Lopez, MD Department of Anesthesia and
Perioperative Medicine, London Health Sciences and St. Joseph’s
Health Care, University of Western Ontario, London, Ontario,
Canada
Yiorgos Alexandros Cavayas, MD, FRCPC Critical Care Fellow,
Université de Montréal, Montréal, Québec, Canada
David-Olivier Chagnon, MD, FRCPC Department of Radiology,
Hôpital Pierre-Boucher, Longueuil, Québec, Canada
Carl Chartrand-Lefebvre, MD, FRCPC Clinical Professor,
Department of Radiology, Centre Hospitalier de l’Université de
Montréal (CHUM), Université de Montréal, Montréal, Québec,
Canada
Robert Chen, MD, FRCPC Assistant Professor of Anesthesia,
Cardiac Anesthesia and Intensive Care, University of Ottawa
Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
Anne S. Chin, MD, FRCPC Assistant Professor, Department
of Radiology, Cardiothoracic Section, Centre Hospitalier de
l’Université de Montréal (CHUM), Université de Montréal,
Montréal, Québec, Canada
Jennifer Cogan, MD, M.Epid, FRCPC Associate Professor,
Department of Anesthesiology, Institut de Cardiologie de
Montréal, Université de Montréal, Montréal, Québec, Canada
Geneviève Côté, MD, MSc, FRCPC Assistant Professor, Pediatric
Cardiac Anesthesiologist, Department of Pediatric Anesthesia,
Centre Hospitalier Universitaire (CHU) Mère-Enfant Sainte-
Justine, Université de Montréal, Montréal, Québec, Canada
Pierre Couture, MD, FRCPC Clinical Associate Professor,
Cardiac Anesthesiology Department, Institut de Cardiologie
de Montréal, Department of Anesthesiology, Université de
Montréal, Montréal, Québec, Canada
André Y. Denault, MD, PhD, FRCPC, FASE, ABIM-CCM, FCCS
Professor, Critical Care Ultrasound Training Program Director,
Department of Cardiac Anesthesiology and Division of
Critical Care of the Department of Cardiac Surgery, Institut
de Cardiologie de Montréal and Division of Critical Care of the
Department of Medicine, Centre Hospitalier de l’Université de
Montréal (CHUM), Université de Montréal, Montréal, Québec,
Canada
Georges Desjardins, MD, FRCPC, FASE Associate Professor of
Anesthesiology, Director of Perioperative Echocardiography,
Department of Anesthesiology, Institut de Cardiologie de
Montréal,Université de Montréal, Montréal, Québec, Canada
Vinay K. Dhingra, MD, FRCPC Clinical Associate Professor of
Medicine, Medical Director Quality Critical Care Vancouver Acute
Clinical Lead, Department of Medicine, Division of Critical Care,
Vancouver General Hospital, University of British Columbia,
Vancouver, British Columbia, Canada
Jean-Nicolas Dubé, MD, MA, FRCPC Clinicial Instructor,
Department of Internal Medicine, Division of Critical Care,
Centre intégré universitaire de santé et de services sociaux de la
Mauricie-et-du-Centre-du-Québec, Université de Montréal, Trois-
Rivières, Québec, Canada
Ashraf Fayad, MD, MSc, FRCPC, FCARCSI, FACC, FASE
Associate Professor, Director of Perioperative Hemodynamic
Echocardiography, Department of Anesthesiology, University of
Ottawa, Ottawa, Ontario, Canada
Gordon N. Finlayson, BSc, MD, FRCPC (Anesth and CCM) Clinical
Assistant Professor, Division of Critical Care, Department of
Anesthesiology and Perioperative Care, Vancouver General
Hospital, University of British Columbia, Vancouver, British
Columbia, Canada
Annie Giard, MD, FRCPC Emergency Room Physician,
Responsible for Echography Training in Emergency Medicine
and Family Medicine, Université de Montréal, ARDMS, Local
Manager for the Training of Independent Practitioner of CEUS,
Department of Emergency Medicine, CIUSS du Nordde-l’Île-
de-Montréal, Installation Hôpital du Sacré-Coeur de Montréal,
Montréal, Québec, Canada
Martin Girard, MD, FRCPC Clinical Associate Professor,
Department of Anesthesiology, Division of Critical Care of the
Department of Medicine, Centre Hospitalier de l’Université de
Montréal (CHUM), Université de Montréal, Montréal, Québec,
Canada
Donald E.G. Griesdale, MD, MPH, FRCPC Assistant Professor,
Department of Anesthesiology, Pharmacology and
Therapeutics, Department of Medicine, Division of Critical Care
Medicine, Chair, Vancouver Medical Advisory Council, Vancouver
General Hospital, University of British Columbia, Vancouver,
British Columbia, Canada
vii
 Han Kim, MD, FRCPC Assistant Professor, Department of
Anesthesia, St. Michael’s Hospital, University of Toronto,
Toronto, Ontario, Canada
Manoj M. Lalu, MD, PhD, FRCPC Clinical Scholar, Department of
Anesthesiology, The Ottawa Hospital, Regenerative Medicine
Program, The Ottawa Hospital Research Institute, Ottawa,
Ontario, Canada
Yoan Lamarche, MD, MSc, FRCSC Assistant Professor of
Surgery, Cardiac Surgeon and Intensivist, Department of
Cardiac Surgery, Institut de Cardiologie de Montréal and
Hôpital du Sacré-Coeur de Montréal, Université de Montréal,
Montréal, Québec, Canada
Moishe Liberman, MD, PhD Associate Professor of Surgery,
Director, CHUM Endoscopic in Tracheobronchial and
Oesophageal Center (C.E.T.O.C.), Marcel and Rolande Gosselin
Chair in Thoracic Surgical Oncology, Scientist, Research
Center, Centre Hospitalier de l’Université de Montréal (CHUM),
Université de Montréal, Montréal, Québec, Canada
Feroze Mahmood, MD, FASE Associate Professor of Anesthesia,
Harvard Medical School, Director Vascular Anesthesia and
Perioperative Echocardiography, Beth Israel Deaconess Medical
Center, Boston, U.S.A.
Ramamani Mariappan, DA, MD, Dip.NB Professor, Christian
Medical College, Vellore, India
Serge McNicoll, MD, CSPQ Cardiologist, Chief of Cardiology
Department of the Department of Medicine, Hôpital Régional
de St-Jérôme, Université de Montréal, Montréal, Québec,
Canada
Massimiliano Meineri, MD Associate Professor of
Anesthesia, Staff Anesthesiologist, Director Perioperative
Echocardiography, Toronto General Hospital, University of
Toronto, Toronto, Ontario, Canada
Scott J. Millington, MD, FRCPC Assistant Professor, Department
of Critical Care Medicine, The Ottawa Hospital, University of
Ottawa, Ottawa, Ontario, Canada
Blandine Mondésert, MD Assistant Professor, Cardiologist,
Division of Cardiac Electrophysiology, Department of Medicine,
Adult Congenital Heart Disease Center, Institut de Cardiologie
de Montréal, Université de Montréal, Montréal, Québec, Canada
Céline Odier, MD, FRCPC Assistant Clinical Professor,
Department of Neurosciences, Centre Hospitalier de
l’Université de Montréal (CHUM), Université de Montréal,
Montréal, Québec, Canada
Sarto C. Paquin, MD, FRCPC Assistant Professor, Department
of Medicine, Division of Gastroenterology, Centre Hospitalier
de l’Université de Montréal (CHUM), Université de Montréal,
Montréal, Québec, Canada
viii
Eric Piette, MD, MSc, FRCPC Clinical Assistant Professor,
Emergency Room Physician, Department of Family Medicine
and Emergency Medicine, Hôpital du Sacré-Coeur de Montréal,
CIUSS Nord de l’Île de Montréal, Université de Montréal,
Montréal, Québec, Canada
Wilfredo Puentes, MD Assistant Professor, Department
of Anesthesia and Perioperative Medicine, London Health
Sciences and St. Joseph’s Health Care, University of Western
Ontario, London, Ontario, Canada
Andrea Rigamonti, MD Assistant Professor, Director,Trauma-
Neuro Anesthesia and Critical Care Fellowship Program,
Departments of Anesthesia and Critical Care, St. Michael’s
Hospital, Department of Anesthesia and Interdepartmental
Division of Critical Care Medicine, University of Toronto, Toronto,
Ontario, Canada
Antoine G. Rochon, MD, FRCPC Assistant Professor, Department
of Anesthesiology, Cardiac Anesthesiology Fellowship Program
Director, Perioperative Transesophageal Echocardiography
Training Program Director, Institut de Cardiologie de Montréal,
Université de Montréal, Montréal, Québec, Canada
Andrew Roscoe, MB ChB, FRCA Consultant in Anaesthesia and
Intensive Care Medicine, Papworth Hospital, Cambridge, U.K.
Karim Serri, MD, FRCPC Associate Professor, Department of
Medicine, Critical Care Division, Hôpital du Sacré-Coeur de
Montréal, Université de Montréal, Montréal, Québec, Canada
Ying Tung Sia, MD, MSc, FRCPC Clinicial Assistant Professor,
Department of Medicine, Division of Cardiology, Centre
Hospitalier Régional de Trois-Rivières and Division of Critical
Care, Institut de Cardiologie de Montréal, Université de
Montréal, Montréal, Québec, Canada
Jean-Claude Tardif, CM, MD, FRCPC, FACC, FAHA, FESC, FCAHS
Professor, Director of the Research Center, Department of
Medicine, Division of Cardiology, Institut de Cardiologie de
Montréal, Université de Montréal, Montréal, Québec, Canada
Annette Vegas, MD, FRCPC, FASE Associate Professor, Staff
Anesthesiologist, Department of Anesthesiology, Toronto
General Hospital, University of Toronto, Toronto, Ontario,
Canada
Claudia H. Viens, MD, FRCPC Assistant Professor, Department
of Anesthesiology, Institut de Cardiologie de Montréal,
Université de Montréal, Montréal, Québec, Canada
Kim-Nhien Vu, MD Diagnostic Radiology Resident, Department
of Radiology, Centre Hospitalier de l’Université de Montréal
(CHUM), Université de Montréal, Montréal, Québec, Canada
Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

How To Use Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxii

List of Videos. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii

Part I
Chapter 1 Ultrasound Imaging: Acquisition and Optimization 1

Chapter 2 Patient Safety and Imaging Artifacts 15

Chapter 3 Normal Cardiac Anatomy and TEE Imaging Planes 29

Chapter 4 Extra-Cardiac Transesophageal Ultrasonography 41

Assessment of Global Ventricular Function, 65

Chapter 5
Pericardium, and Cardiomyopathy

Chapter 6 Basic Regional Ventricular Systolic Function 87

Chapter 7 Basic Valve Diseases 103

Chapter 8 Intra-cavitary Contents 131

Chapter 9 Basic Hemodynamic Assessment 157

Chapter 10 Related Diagnostic Imaging Modalities 177

Chapter 11 Simple Congenital Heart Disease in Adults 195

Chapter 12 Echocardiography in Non-Cardiac Procedures and Trauma 205

ix
 Part II
Chapter 13 Critical Care Ultrasound Examination of the Nervous System 229

Chapter 14 Critical Care Examination of the Respiratory System 249

Chapter 15 Critical Care Examination of the Cardiovascular System 271

Chapter 16 Critical Care Examination of the Abdomen 293

Chapter 17 Ultrasound for Critical Care Procedures 321

Chapter 18 Ultrasound-Guided Vascular Access and Examination 333

Chapter 19 Training Guidelines and Simulation 365

Chapter 20 Mock Transesophageal Echocardiography Examination (On-Line)

Mock Critical Care Ultrasound Examination (On-Line)

Appendix 1 Recommended Views in Transesophageal Echocardiography 381

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403

x
Foreword
Since I first trained in Critical Care Medicine (CCM) in the
mid-1980s at the University of Pittsburgh, where André
Denault then followed, the intensive care unit (ICU) has
changed dramatically with regards to the acuity, severity
and complexity of the patient population. As clinicians at
the bedside, the questions we ask are increasingly complex
and the answers we seek are more precise. Non-invasive
monitoring is more refined and ultrasound (US) technology
has become the modern clinician’s stethoscope. US moni-
toring has gone from echocardiography being performed
by a cardiologist in the occasional ICU patient two decades
ago, to the intensivist obtaining either a focused or compre-
hensive echocardiogram and performing US examination
of the thoracic and abdominal contents, as well as guiding
vascular access and monitoring neurological status. Since
all the organs of interest to the CCM physician are accessible
by US imaging, the scope of practice is rapidly growing in
popularity. This is matched only by the challenge we face
in mastering the technology, recognizing the limits, inter-
preting the results and teaching ultrasound to our students,
residents, fellows and colleagues.
It is with these objectives in mind that this textbook on US
imaging was wonderfully conceived by the team of experts
that André has put together. The chapters proceed in more or
less the same fashion as US imaging has progressed through
the last decades. From basic principles and image acquisition,
the reader evolves to transesophageal echocardiography
(TEE) and assessing intra-cardiac and extra-cardiac struc-
tures and function, as well as all other organs accessible to
the TEE platform. The reader then proceeds to transthoracic
echocardiography and focused US imaging of the pulmonary
and abdominal contents, with a welcome addition regarding
brain monitoring. Perioperative and ICU assessments are
well dealt with, as are ICU procedures and vascular access in
the critically ill patient. Each chapter is rigorously structured
and very well referenced with diagrams, intra-operative
photographs, illustrations and videos to optimize interactive
learning for both the novice, as well as the experienced
clinician. Tables and figures abound throughout the text in
pragmatic support and as a reminder of concepts, classi-
fications and equations. Last but not least are the chapters
dedicated to simulation training and examination, which are
of the utmost importance to those involved in structuring US
teaching programs and in abiding by society guidelines and
recommendations.
Dr Denault and his team are to be complimented for this
comprehensive and rigorous effort in mastering US imaging
whether in the operating room or the ICU. It is a reflection
of where US imaging has come from and where it is going.
However, for US imaging to evolve, we must make certain
it is well performed, interpreted and leads to appropriate
decision making. This book strives to achieve these goals.
Our CCM training program at the University of Montreal
believes US imaging is now an obligatory skill to be mas-
tered during fellowship training. Our fellows go through a
3-month structured US training program in order to become
proficient in basic US imaging of the heart and other organs
through TEE, TTE and focused US examination. This book
recreates how our fellows are being trained and as such, is
our textbook of reference. Years of clinical observation and
correlation with US imaging by clinicians have gone into
this book and I am extremely proud of what it has become
and what it will achieve.
Jean-Gilles Guimond MD, FRCPC, FCCP
Program Director, Critical Care Medicine
Université de Montréal, Quebec, Canada
xi
Preface
In 2005, we published our first Transesophageal Echo-
cardiography Multimedia Manual,1 which was followed in
2011 by a second edition.2 These manuals were written to
help prepare practising anesthesiologists and trainees in
cardiothoracic anesthesia and critical care for the National
Board of Echocardiography (NBE) Examination of Special
Competence in Advanced Perioperative Transesophageal
Echocardiography (TEE). In the second edition, several
chapters were dedicated to the role of TEE in non-cardiac
surgical applications and in the intensive care unit (ICU).
The field of TEE has matured significantly over the last
decade. In addition, with the widespread availability of
ultrasound, there is a growing interest for the applications
of bedside ultrasound in the ICU, non-cardiac operating
room, and emergency medicine. Furthermore, training
guidelines in basic TEE3 and in critical care ultrasound were
published.4,5 Certification in both modalities through the
NBE and the American College of Chest Physicians (ACCP)
have also became available.
The goal of this manual also remains simple: to prepare
anesthesiologists, critical care physicians, fellows, and
residents for the NBE Basic Perioperative TEE examination
and ACCP critical care ultrasonography certification. This
book, whose editors and the majority of its authors are
from Canadian universities, also covers the Canadian
recommendations for critical care ultrasound training
and competency.6 It is the opinion of the editors that all
critical care physicians and general anesthesiologists will
eventually become trained in both basic TEE and critical
care ultrasound. At the Université de Montréal in 2013,
the Critical Care Program Director, Dr Jean-Gilles Guimond
asked me to initiate comprehensive ultrasound training for
all our fellows. This is the manual that we will be using.
The manual is divided in two parts. Part I consisting of
Chapters 1 to 12 is dedicated to basic TEE. Part II relates to
focused bedside ultrasound and includes Chapters 13 to 19.
In Chapter 20, two mock exams inspired by the NBE Basic TEE
and the ACCP exam are presented, and additional materials
are available from the CRC website: http://www.crcpress.
com/product/isbn/9781482237122 In Part I, we introduce for
the first time a chapter on extra-cardiac TEE. In addition,
in Part II, there is a chapter on ultrasound of the brain.
These unconventional areas will become more important
in the future as clinicians evaluate not only the etiology of
hemodynamic instability, but also the impact on multiple
organs such as the kidney, liver, splanchnic perfusion,
and brain. This manual is unique because the editors and
authors represent several different fields of clinical practice
in anesthesia, internal medicine, emergency medicine,
and surgery. General anesthesiologists, cardiothoracic
anesthesiologists and neuro-anesthesiologists have shared
their unique expertise alongside critical care physicians,
cardiologists, gastroenterologists, neurologists, emergency
medicine specialists, abdominal and thoracic radiologists,
and cardiac and thoracic surgeons. I sincerely thank all the
authors who have taken the time to contribute to this work.
Such a manual would not have been possible without
the support of my four editors. I am very grateful for
their contributions. Dr Annette Vegas is a cardiothoracic
anesthesiologist with a critical care appointment at the
Toronto General Hospital. Annette has been an editor since
2009 and has continuously raised the quality and pertinence
of our educational material. She has already published
several books in TEE that are carried by ultrasound trainees
worldwide. She has contributed to an outstanding free
educational website in ultrasound translated into several
languages (http://pie.med.utoronto.ca). Her dedication to
this manual has been unsurpassed and is remarkable, as
it was for the second edition of the TEE manual. Dr Yoan
Lamarche is a cardiac surgeon, additionally certified
in critical care medicine and TEE, working at both the
Montreal Heart Institute (MHI) and Hôpital du Sacré-Coeur.
He is the director of the MHI Cardiac Surgical ICU. Yoan’s
natural leadership, educational skills, common sense, and
surgical experience gave this manual clarity and a unique
perspective. Dr Jean-Claude Tardif is a cardiologist and the
director of the MHI Research Center. Since the perioperative
anesthesia TEE program started in 1999 at the MHI,
Jean-Claude has strongly supported the Anesthesiology
Department in TEE development and expertise. Dr Tardif
has played an important role participating in developing
our manuals and has also made available the MHI research
environment in order to improve the care of our patients
in the operating room and the ICU. I met Dr Pierre Couture
in 1993 when he returned from Paris after completing his
cardiac anesthesia fellowship. We shared a common passion
for ultrasound applications and have been working and
publishing together ever since. Pierre was our former Chief
of Cardiac Anesthesia at the MHI. He has been helping me
in all aspects of the manual, completely rewriting some
chapters in order to offer the best to our students and
readers. His generosity, kindness, amazing TEE knowledge,
and teaching skills are well appreciated in our institution.
Several individuals have played a significant role
in the creation of this manual. Mr Denis Babin is the
webmaster of the Department of Anesthesiology of the
Université de Montréal and my research assistant since
1998. I am fortunate to have such an amazing assistant.
His diverse talents in computer science, graphic design,
database management, and communication provide the
key elements that have made all our manuals so appealing.
There is not a single figure or video that Denis has not
xiii
 touched, improved or converted … I often say, “Denis, would
you mind ‘babinising’ this?” Special thanks for the support
and advice of my current Chief of Cardiac Anesthesia at
the MHI must go to Dr Alain Deschamps. I also thank all
my colleagues, anesthesiologists, critical care physicians,
cardiac surgeons, and cardiologists at the MHI who have
supported and alerted me to interesting cases. Likewise, I
thank my critical care colleagues in the ICU of the Centre
Hospitalier de l’Université de Montréal.
This work would not have been possible without
financial support. I would like to thank especially Dora and
Avrum Morrow. Meeting Mr Avrum Morrow in Old Montreal
and seeing the Avmor Collection was an unforgettable
moment in my life. In 2014, I had the privilege of being
chosen for the Richard I Kaufman Endowment Fund in
Anesthesia and Critical Care. This support will allow us to
continue our educational and research activities for the
coming years. My gratitude to the Kaufman family is beyond
words. All this support has been completely dependent on
the MHI Foundation and its director Mélanie LaCouture.
The MHI Foundation has been supporting me every year
since 1999 and played a key role in contacting those who
are supporting this manual and our future development.
Special thanks to Josée Darche from the MHI Foundation.
In addition, my appreciation goes to MHI director Dr
Denis Roy and to Dr Annie Dore who is responsible for
all MHI educational activities, as both have also believed
in our initiatives. I am also indebted to the Fondation
de l’Association des Anesthésiologistes du Québec and
president Dr Gilles Plourde and Mr Joseph Bestravos from
Sonosite/Fuji for their generous support. Credit must also be
given to Mr Fainman for his generous donation that allowed
us to buy the first X-Porte ultrasound system from Sonosite/
Fuji in Canada. Several figures in this book came from this
equipment.
Dr Robert Amyot, staff cardiologist at the Hôpital du
Sacré-Coeur has been an author in our two previous TEE
manuals. In 2014 Robert became the president of CAE
Healthcare. We acknowledge his support in allowing us to
enhance many figures in this manual by extensively using
the Vimedix simulator (CAE, Healthcare Canada) to obtain
REFERENCES
1. Denault AY, Couture P, Tardif JC, Buithieu J. Transesophageal
Echocardiography Multimedia Manual: A Perioperative
Transdisciplinary Approach. New York: Marcel Dekker, 2005.
2. Denault AY, Couture P, Vegas A, Buithieu J, Tardif JC.
Transesophageal Echocardiography Multimedia Manual, Second
Edition: A Perioperative Transdisciplinary Approach. New York:
Informa Healthcare, 2011.
3. Reeves ST, Finley AC, Skubas NJ, Swaminathan M, Whitley
WS, Glas KE, Hahn RT, Shanewise JS, Adams MS, Shernan
SK. Basic perioperative transesophageal echocardiography
examination: a consensus statement of the American Society
of Echocardiography and the Society of Cardiovascular
Anesthesiologists. J Am Soc Echocardiogr 2013; 26: 443–56.
xiv
anatomic illustrations and videos. In addition, physicians
in Canada have free institutional access to Anatomy.tv
powered by Primal Picture (info@primalpictures.com)
through Wolters Kluwer Health. This educational site allows
clinicians to learn and teach anatomy from a 3D atlas. We
are so grateful to both of these companies for allowing us to
use their interface throughout the manual.
Finally, many colleagues, residents, and fellows at the
MHI have graciously reviewed chapters of this manual,
making suggestions and pointing out corrections. I would
like to thank all of them which are listed just below.
I hope that you will enjoy reading the 1st Edition of the
Basic Transesophageal and Critical Care Ultrasound textbook.
André Denault MD, PhD, FRCPC, FASE, ABIM-CCM, FCCS
Dr William Beaubien-Souligny
Dr Alexandros Cavayos
Dr David Claveau
Dr Joseph Dahine
Dr André Dubé
Dr Roberto Eljaiek
Dr Jessica Forcillo
Dr Caroline Gebhard
Dr Brian Grondin-Beaudoin
Dr Jean-Gilles Guimond
Dr Vincent Lecluyse
Dr Gabrielle Migner-Laurin
Dr Alex Moore
Mrs Antoinette Paolitto
Dr Daniel Parent
Dr Élise Rodrigue
Dr Catalina Sokolof
Dr Francis Toupin
Dr Claudia Viens
Dr Han Ting Wang
4. Mayo PH, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod
C, Kaplan A, et al. American College of Chest Physicians/La
Société de Réanimation de Langue Française statement on
competence in critical care ultrasonography. Chest 2009; 135:
1050–60.
5. Via G, Hussain A, Wells M, Reardon R, Elbarbary M, Noble VE,
et al. International evidence-based recommendations for
focused cardiac ultrasound. J Am Soc Echocardiogr 2014; 27:
683.
6. Arntfield R, Millington S, Ainsworth C, Arora R, Boyd J,
Finlayson G, et al. Canadian recommendations for critical care
ultrasound training and competency. Can Respir J 2014; 21:
341–45.
Abbreviations
2C two-chamber Ant anterior

2D two-dimensional Ao aorta

4C four-chamber AoV aortic valve

5C five-chamber AP anterior–posterior

A amplitude AR atrial reversal

A peak late diastolic TMF or TTF velocity AR aortic regurgitation

A atrial contraction AR dur atrial reversal pulmonary venous flow velocity

duration
a′ peak late diastolic mitral or tricuspid annular
velocity ARDS acute respiratory distress syndrome

A dur duration of TMF A-wave AS apical septal / anteroseptal

A4C apical four-chamber ASA American Society of Anesthesiologists

AA apical anterior aSAH aneurysmal subarachnoid hemorrhage

AA axillary artery Asc Ao ascending aorta

AAA abdominal aortic aneurysm ASD atrial septal defect

AAL anterior axillary line ASE American Society of Echocardiography

Asr late diastolic strain rate

AC attenuation coefficient
At peak late diastolic tricuspid annular velocity
ACA anterior cerebral artery
AV axillary vein / aortic valve
ACC American College of Cardiology
AVA aortic valve area
ACCP American College of Chest Physicians
AVC aortic valve closure
ACES Abdominal Cardiac Evaluation with Sonography
in Shock AVM arteriovenous malformation
ACGME Accreditation Council for Graduate Medical AW anterior window
Education
BA basal anterior
ACLS advanced cardiac life support
BA basilar artery
ACoA anterior communicating artery
BAL basal anterolateral
Adr adrenal
BART Blue Away Red Towards (common color map)
Adre adrenaline
BAS basal anteroseptal
AHA American Heart Association
BHI breath holding index
AIN apical inferior
BIN basal inferior
AJV anterior jugular vein
BIL basal inferolateral
AL apical lateral / anterolateral
BIS basal inferoseptal
AL area-length method
BSA body surface area
Am peak late diastolic MAV
C carotid segments
AMVL anterior mitral valve leaflet
C propagation speed

xv
 CA carotid artery CWD continuous wave Doppler
CAD coronary artery disease CXR chest radiography
CAE Canadian Aviation Electronics d diameter
CAS carotid angioplasty and stenting D diastolic PVF or HVF velocity
CBF cerebral blood flow D diastolic
CBFV cerebral blood flow velocity D1 first diagonal
CCA cerebral circulatory arrest D2 second diagonal
CCCS Canadian Critical Care Society DAP diastolic arterial pressure
CCE critical care echocardiography db decibel
CCS Canadian Cardiovascular Society DBP diastolic blood pressure
CCTA coronary computed tomography angiography DCI delayed cerebral ischemia
CEA carotid endarterectomy DE-CMR delayed enhanced cardiovascular magnetic
CFD color flow Doppler resonance

CFS cerebrospinal fluid Des Ao descending aorta

CHD congenital heart disease DF duty factor

cm centimeter DT deceleration time

CME continuing medical education DVT deep venous thrombosis

CMR cardiovascular magnetic resonance E early diastolic TMF or TTF velocity

CO cardiac output E early filling

CO2 carbon dioxide e' peak early diastolic mitral or tricuspid annual
velocity
CPB cardiopulmonary bypass
ECA external carotid artery
CPP cerebral perfusion pressure
ECG electrocardiogram or electrocardiographic
CPR cardiopulmonary resuscitation
ECMO extracorporeal membrane oxygenation
CS coronary sinus
EDA end-diastolic area
CSA cross-sectional area
EDV end-diastolic velocity
CSE Canadian Society of Echocardiography
EF ejection fraction
CT celiac trunk
eFAST extended FAST
CT computed tomography
EI eccentricity index
CTA computed tomography angiogram
EIV external iliac vein
CTP computed tomography perfusion
Em early diastolic MAV
CVC central venous catheters
ER emergency room
CVP central venous pressure
ERO effective regurgitant orifice
CW continuous wave
ESA end-systolic area

xvi
ESLD end-stage liver disease HV hepatic vein

Esr early diastolic strain rate HVF hepatic venous flow

ET ejection time HVLT half value layer thickness

Et peak early diastolic tricuspid annular velocity IN inferior

ETCO2 end-tidal carbon dioxide IAS interatrial septum

ETT endotracheal tube IA innominate artery

EUS endoscopic ultrasound scanning IABP intra-aortic balloon pump

EV eustachian valve ICA internal carotid artery

EVAR endovascular repair of aortic aneurysm ICCU Imaging Curriculum in Critical Care Ultrasound

f frequency (Hz) ICM intercostal muscle

FA femoral artery ICP intracranial pressure

FAC fractional area change ICU intensive care unit

FAST Focused Assessment with Sonography in Trauma IJV internal jugular vein

Fd Doppler frequency shift IL inferolateral

FL false lumen IMA internal mammary arteries

FO foramen ovale or fossa ovalis IN inferior

FP foramen primum In-Out inflow-outflow

FS foramen secundum IOA Iindex of autoregulation

FV femoral vein IRC intensity reflection coefficient

FVd end-diastolic flow velocity IS inferoseptal

FVm mean flow velocity IVC inferior vena cava

FVR flow velocity ratio IVCT isovolumic contraction time

FVs systolic flow velocity IVRT isovolumic relaxation time

FW frontal window IVS interventricular septum

g gram IVUS intravascular ultrasound

GCCUS General Critical Care Ultrasound J joules

GE gastroesophageal L lateral

GI gastrointestinal LA left atrium

GLS global longitudinal strain LAA left atrial appendage

H horizontal LACA left anterior cerebral artery

HAF hepatic artery flow LAD left anterior descending

HAV hemiazygos vein LAFB left atrio-femoral bypass

HCM hypertrophic cardiomyopathy LAP left atrial pressure

HITS hyperintensity thromboembolic signal LAX long-axis

HR heart rate LCC left coronary cusp

HU Hounsfield unit LCCA left common carotid artery

xvii
 LCX left circumflex artery MCA middle cerebral artery

LGC lateral gain control ME mid-esophageal

LGE late-gadolinium-enhancement MFV mean flow velocity

LH left heart MHV middle hepatic vein

LHV left hepatic vein MI mechanical index

LIJV left internal jugular vein Mid middle

LK left kidney MIL mid-inferolateral

LLL left lower lobe MIN mid-inferior

LM left main MIS mid-inferoseptal

LMCA left middle cerebral artery MLS midline shift

LPV left portal vein mm millimeter

LSCA left subclavian artery mmHg millimeter of mercury

LSVC left-sided superior vena cava M-mode motion mode

LT liver transplantation Mn mean

LTICA left terminal internal carotid artery MOC maintenance of competence

L-to-R left-to-right MOD method of disk

LUL left upper lobe MPA main pulmonary artery

LUPV left upper pulmonary vein MPI myocardial performance index

LV left ventricle or left ventricular MR mitral regurgitation

LVD left ventricular minor-axis diameter MRI magnetic resonance imaging

LVEDA left ventricle end-diastolic area ms millisecond

LVEDD left ventricle end-diastolic diameter MS mitral stenosis

LVEDP left ventricular end-diastolic pressure MV mitral valve

LVEDV left ventricle end-diastolic volume MVA mitral valve area

LVEF left ventricular ejection fraction MVO mitral valve opening

LVESA left ventricular end-systolic area MW middle window

LVESP left ventricular end systolic pressure NBE National Board of Echocardiography

LVIDd left ventricular internal diameter at end-diastole NCC non-coronary cusp

LVOT left ventricular outflow tract NL nipple line

LVOTO left ventricular outflow tract obstruction Norad noradrenaline

m meter NS not specified

MA mid-anterior OA ophthalmic artery

MAL mid-anterolateral ONSD optic nerve sheath diameter

MAS mid-anteroseptal OR operating room

MAV mitral annular velocity P power

Max maximal P pressure

xviii
P1 posterior leaflet Pra right atrial pressure

PA pulmonary artery PREDV pulmonary regurgitation end-diastolic velocity

PAC pulmonary artery catheter PRF pulse repetition frequency

PaCO2 arterial carbon dioxide tension PRI pulmonary regurgitation index

PAEDP pulmonary artery end-diastolic pressure PRP pulse repetition period

PAL posterior axillary line PRV right ventricular pressure

Pan pancreas PSL parasternal line

PaO2 arterial oxygen tension PT pulmonary trunk

Par systolic radial blood pressure PTE Perioperative Transesophageal

Echocardiography
PASP pulmonary artery systolic pressure
PV pulmonic valve
PC pericardial cyst
PV pressure–volume
PCA posterior cerebral artery
PVAC pulmonic valve anterior cusp
PCoA posterior communicating artery
PVF pulmonary venous flow
PCWP pulmonary capillary wedge pressure
PVLC pulmonic valve left cusp
PD pulse duration
PVR pulmonary vascular resistance
PE pericardial effusion
PW pulsed-wave
PE pulmonary embolism
PWD pulsed-wave Doppler
PEA pulseless electrical activity
PWT posterior wall thickness
PecM pectoralis muscle
PWTd posterior wall thickness diameter
PEEP positive end-expiratory pressure
Py pylorus
PFO patent foramen ovale
Qp pulmonary flow
PG pressure gradient
Qs systemic flow
PHT pressure half-time
R radius
PI pulsatility index
RA right atrium or right atrial
PICC peripherally inserted central catheter
RAA right atrial appendage
PISA proximal isovelocity surface area
RACA right anterior cerebral artery
PM papillary muscle
RAP right atrial pressure
PMD power mode Doppler
RCA right carotid artery
Pms mean systemic venous pressure
RCA right coronary artery
PMV prosthetic mitral valve
RCC right coronary cusp
POCUS point-of-care ultrasound
RH right heart
Post posterior
RHV right hepatic vein
PoVF portal venous flow
RI resistance index
Ppa pulmonary artery pressure
RIJV right internal jugular vein
Ppl pleural pressure
RLPV right lower pulmonary vein
PR pulmonary regurgitation

xix
 RMCA right middle cerebral artery SD standard deviation

RML right middle lobe sec second

ROSC return of spontaneous circulation SEC spontaneous echo contrast

RPA right pulmonary artery SIRS systemic inflammatory response syndrome

RPV right portal vein SL strain longitudinal

R-to-L right-to-left SMA superior mesenteric artery

RUL right upper lobe SP septum primum

RUPV right upper pulmonary vein SPECT single photon emission computer tomography

RUSH Rapid Ultrasound for Shock and Hypotension SPL spatial pulse length

RV right ventricle or right ventricular SPTA spatial peak temporal average

RVD right ventricular diameter SR strain rate

RVEF right ventricular ejection fraction SS septum secundum

RVOT right ventricular outflow tract Ssr peak systolic strain rate

RVOTO right ventricular outflow tract obstruction STJ sinotubular junction

Rvr resistance to venous return SV stroke volume

RVSP right ventricular systolic pressure SVC superior vena cava

RWMA regional wall motion abnormalities SVF splenic venous flow

RWT relative wall thickness SWT septal wall thickness

S septal SWTd septal wall thickness in diastole

S systolic SX sub xyphoid

S systolic pulmonic or hepatic venous flow velocity T period

s' systolic tricuspid annular velocity TAAA thoraco-abdominal aortic aneurysm

S wave inflow during systole TAMV time-averaged mean velocity

SAM systolic anterior motion TAPSE tricuspid annular plane systolic excursion

SaO2 oxygen saturation TAV tricuspid annular velocity

SAP systolic arterial pressure TCCS transcranial color-coded duplex sonography

SAX short-axis TCD transcranial Doppler

SBP systolic blood pressure TD thermodilution

SC subcostal TDI tissue Doppler imaging

SCA Society of Cardiovascular Anesthesiologists TEE transesophageal echocardiography

SCA subclavian artery TEVAR thoracic endovascular aortic repair

SCA Society of Cardiovascular Anesthesiologists TG transgastric

SCD sickle cell disease TGC time gain compensation

ScO2 brain saturation Th wall thickness

SCT subcutaneous tissue TICA terminal internal carotid artery

SCV subclavian vein TL true lumen

xx
TMF transmitral flow VIRTUAL Visual Interactive Resource for Teaching,
Understanding and Learning
TPR total peripheral resistance
Vmax maximum jet velocity
TR tricuspid regurgitation
Vmv mitral valve regurgitant velocity
TS tricuspid stenosis
Vp flow propagation velocity
TTE transthoracic echocardiography
Vpeak peak velocity
TTF transtricuspid flow
VR venous return
TV tricuspid valve
VSD ventricular septal defect
TVA tricuspid valve area
Vt1/2 velocity at the pressure half-time point
TVAL tricuspid valve anterior leaflet
VTI velocity time integral
TVPL tricuspid valve posterior leaflet
VTR peak tricuspid regurgitant velocity
UE upper esophageal
W watts
US ultrasound
WMA wall motion abnormalities
V vertical
WMSI regional wall motion score index
VA vertebral arteries
Z impedance
Vaso vasopressin
σ stress
VC vena contracta
λ wavelength
Vel velocity

xxi
 How to Use
Sketch and 3D icon correlation and superposition

LA SVC

IVC SVC
LA RA

RA
IVC

LA

LV LA

LV

Ao Ao

LV LA RV RV LA

RV LA LV LV

Ao

This symbol used in the legend indicates the presence of

 additional video in relation to the figure available on the Web.

The human body icon indicates how the patient was

positioned when images or videos were obtained.

In order to see the video related to the figure, use an application

to scan the QR code or with the mouse, click on short URL to
view video. The letter(s) before URL address is in relation to
which part of the figure, the video is associated.
http://goo.gl/bba15t

xxii
List of Videos
Video title and figure Pleural hematoma 4.9d
number Atelectasis 4.10d
Pneumonia after
Chapter 2 lobectomy 4.11a
Mechanical and thermal Pneumonia after
indices 2.6b lobectomy 4.11b
Mechanical and thermal Pneumonia after
indices 2.6e lobectomy 4.11c
Reverberation 2.7i Pneumonia after
Reverberation 2.7ii lobectomy 4.11d
Comet tail and ring down Subcarinal lymph node
artifacts 2.8a 4.14a
Refraction 2.9a Azygos and hemiazygos
Edge shadowing 2.10a venous system 4.16
Side lobe artifact 2.11a Azygos vein 4.17a
Side lobe artifact 2.11c Azygos vein 4.17c
Range ambiguity 2.12a Examination of the
Acoustic shadowing 2.13c stomach 4.20d
Enhancement and dropout Examination of the
artifacts 2.14a stomach 4.20e
Near-field clutter 2.15a Examination of the
stomach 4.20f
Chapter 3 Gastric abnormalities 4.21a
TEE probe manipulation Gastric abnormalities 4.21b
3.2 Gastric abnormalities 4.21c
ME 4CH view 3.4a Spleen anatomy and
ME 4CH view 3.4c position 4.23
ME two-chamber view 3.5a Spleen 4.24a
ME LAA view 3.6a Spleen 4.24b
ME LAA view 3.6c Spleen 4.24c
ME LAA view 3.6i Spleen 4.24d
ME long-axis view 3.7 Left kidney 4.25d
LVOT obstruction 3.8a & b Left kidney 4.26a
LVOT obstruction 3.8d & e Left kidney 4.26b
Asc Ao views 3.9a Liver 4.28
Asc Ao views 3.9c Hepatic veins 4.29a
Asc Ao views 3.9e Hepatic veins 4.29c
ME Asc Ao short-axis view Hepatic veins 4.29e
3.10a Portal vein 4.30a
ME Asc Ao short-axis view Hepatic artery 4.31a
3.10d Hepatic artery 4.31b
ME AoV short-axis view Hepatic pathologies 4.32a
3.11a Hepatic pathologies 4.32b
ME right ventricular Hepatic pathologies 4.32c
inflow/outflow view Hepatic pathologies 4.32d
3.12a Portal hypertension 4.34d
ME bicaval view 3.13a Whale tail sign 4.35c
Transgastric mid short- Whale tail sign 4.35d
axis view 3.14a Splenic Doppler flow 4.38a
Descthoracic Ao views Splenic Doppler flow 4.38d
3.15a Abnormal splenic venous
Descthoracic Ao views flow 4.39b
3.15c Abnormal splenic venous
flow 4.39e
Chapter 4
Pulmonary regions 4.1a & b Chapter 5
Pulmonary references Preload 5.5a & b
points 4.2 Preload 5.6a & d
Left lung examination 4.5a Respiratory variation of
Left lung examination 4.5e the SVC 5.7a
Left lung examination 4.5I Respiratory variation of
Right lung examination the SVC 5.7c
4.6a Fractional area change
Right lung examination 5.9a & c
4.6e Eccentricity index 5.12c-d
Right lung examination Eccentricity index 5.12e-f
4.6I TAPSE 5.13
Complex pleural effusion Pulmonary vein Doppler
4.7a 5.15a
Complex pleural effusion Pulmonary vein Doppler
4.7d 5.15d
Hemothorax 4.8 Pericardial effusion 5.18a
Pleural hematoma 4.9b Cardiac tamponade
Pleural hematoma 4.9c 5.19b & e
Pleural and pericardial 7.32a Carcinoid heart disease
effusions 5.20a Pulmonary artery post- 8.33d
Hypertrophic stenotic aneurysm 7.32c IABP catheter 8.34a
cardiomyopathy 5.23a Normal pulmonic valve ECMO cannula 8.35a
Dilated cardiomyopathy (PV) 7.33b ECMO cannula 8.35b
5.24a Mechanical heart valves ECMO cannula 8.35c
Takotsubo 5.26a 7.34b
Takotsubo 5.26b Mitral valve (MV) Chapter 9
Takotsubo 5.26c bioprostheses 7.36a Brain-heart syndrome 9.7a
Takotsubo 5.26d Mitral valve (MV) Brain-heart syndrome 9.7b
Takotsubo 5.26e bioprostheses 7.36a Brain-heart syndrome 9.7c
Takotsubo 5.26f Mechanical bileaflet ECG changes 9.8b
dysfunction 7.37a Arterial pressure
Chapter 6 Mechanical bileaflet waveforms 9.9a
LV function 6.2a,b, & e dysfunction 7.37c Arterial pressure
LV function 6.3a,b, & e Washing jets 7.38a waveforms 9.9b
Left coronary artery 6.4a Arterial pressure
Left coronary artery 6.4c Chapter 8 waveforms 9.9c
Right coronary artery 6.5a Persistent LSVC 8.2a Arterial pressure
Right coronary artery 6.5c Atrial septal aneurysm waveforms 9.9d
Right coronary artery 6.5e 8.3a Arterial pressure
ECMO 6.6a Eustachian valve and waveforms 9.9ei
ECMO 6.6b Chiari network 8.5a Arterial pressure
Radial strain 6.11a Eustachian valve and waveforms 9.9eii
LV function 6.13a Chiari network 8.5c Capnography and
LV function 6.13b Eustachian valve and ventilator flow-time
Apical thrombus 6.14a Chiari network 8.5d waveforms 9.10b
Apical thrombus 6.14d Lipomatous hypertrophy V wave 9.11a
Ruptured papillary muscle 8.6a V wave 9.11a
6.15a Papillary muscle as a V wave 9.11b
Inferior LV aneurysm 6.16a pseudomass 8.7a V wave 9.11c
Apical ischemic VSD 6.18c Papillary muscle as a V wave 9.11c
Apical ischemic VSD 6.18d pseudomass 8.7e Systolic blood pressure 9.12
Ischemic VSD 6.19b False tendon 8.8c LVOT obstruction 9.13a
RV ischemia 6.20 Moderator band 8.9a LVOT obstruction 9.13d
Lambl's excrescence 8.10a RVOT obstruction 9.14a
Chapter 7 Endocarditis 8.11a RVOT obstruction 9.14e
AoV anatomy 7.1a Endocarditis 8.11c RVOT obstruction 9.14f
AoV anatomy 7.1a Endocarditis 8.11d Acute pulmonary emboli
Ao root anatomy 7.3a LV thrombus and 9.15a
Ao stenosis 7.4a & c hematoma 8.13a Acute pulmonary
Bicuspid AoV 7.5a Spontaneous echo contrast emboli9.15b
Bicuspid AoV 7.5e 8.14a Cardiac tamponade 9.16a
Unicuspid unicommissural Spontaneous echo contrast Cardiac tamponade 9.16c
AoV 7.6a 8.14c Left-sided pneumothorax
Supravalvular Ao Paradoxical embolism 9.17b
membrane 7.7c 8.15a Compression of the RA
TG LAX View 7.8a Paradoxical embolism 9.18a
Deep TG views 7.9a 8.15d IVC occlusion during
TG views of AoV 7.10a Intra-cardiac thrombus Fontan procedure 9.19a
TG views of AoV 7.10e 8.18a Endocarditis with Ao root
ERO area 7.12a Intra-cardiac thrombus abscess 9.20a
Ao Regurgitation 7.13a 8.18e Endocarditis with Ao root
Mitral valve (MV) anatomy Chronic pulmonary abscess 9.20a
7.16e embolism 8.19a Endocarditis with Ao root
LAA thrombus 7.18a Endocarditis 8.20a abscess 9.20c
LAA thrombus 7.18c Endocarditis 8.20b Pneumonia 9.21a
LAA velocities 7.21a Endocarditis 8.20e Peritoneal bleed 9.22a
TEE assessment of MV Tricuspid valve (TV)
7.23c endocarditis 8.21a Chapter 11
TEE assessment of MV Endocarditis 8.22a Patent foramen ovale
7.23e Endocarditis 8.22c (PFO) 11.2a & b
TEE assessment of MV Left atrial myxoma 8.24a ASD secundum 11.5a
7.23g Left atrial myxoma 8.24c ASD secundum 11.5d
TEE assessment of MV 7.23I Fibroelastoma 8.25d Patent Foramen Ovale
Rheumatic tricuspid valve Fibroma 8.26a (PFO) 11.6c
(TV) 7.26a Fibroma 8.26c Muscular VSD 11.8a
Rheumatic tricuspid valve Pericardial cyst 8.28a Muscular VSD 11.8c
(TV) 7.26c Pericardial cyst 8.28d
TR 7.27a Renal cell cancer 8.32a Chapter 12
Pulmonic valve (PV) 7.31a Carcinoid heart disease TDI for RV function 12.3c
Pulmonic valve (PV) 7.31a 8.33a Air emboli 12.7a
Pulmonary artery post- Carcinoid heart disease LUPV stenosis 12.8a
stenotic aneurysm 8.33c Transverse Ao 12.11 a &c
xxiii
 Left atrio-femoral bypass thrombosis 14.22a coronal upper and mid Pericardiocentesis 17.5a PICC insertion 18.29a
12.13a Pneumothorax 14.24a abdominal US views Pericardiocentesis 17.5b PICC insertion 18.29d
Guidewire position 12.15a Pneumothorax 14.25a 16.7h Pericardiocentesis 17.5c PICC position 18.30a
Ao arch vessels 12.16a Barcode sign 14.27 Gallbladder 16.8d Pericardiocentesis 17.6a PICC insertion 18.32
Pleural effusion 12.19b Lung point in M-mode Gallbladder 16.8b Pericardiocentesis 17.6b Intravascular Doppler tip
Pleural effusion 12.19c 14.28 Gallbladder 16.8c Pericardiocentesis 17.6c tracking system 18.33
LVOTO and hypoxemia Pleural effusion 14.29 Kidney 16.9a Pericardiocentesis 17.6c Radial artery 18.37a
12.21a Empyema 14.31 Kidney 16.9b Pleurocentesis 17.1 Radial artery 18.37d
LVOTO and hypoxemia Percutaneous Spleen 16.10a Pleurocentesis 17.11a Arterial vascular
12.21c tracheostomy 14.34c Spleen 16.10b Pleurocentesis 17.11b pathologies 18.39a
LVOTO and hypoxemia Spleen 16.10b Pneumothorax 17.12b Arterial vascular
12.21d Chapter 15 Abdominal aorta 16.12b Pneumothorax 17.13a pathologies 18.39b
IVC stenosis 12.22a FOCUS exam 15.2a Abdominal aorta 16.12c Pneumothorax 17.13c Arterial vascular
IVC stenosis 12.22b FOCUS exam 15.2c Abdominal aorta 16.12d Pneumothorax 17.13c pathologies 18.39c
IVC stenosis 12.22c FOCUS exam 15.2e Abdominal aorta branches Pneumothorax 17.13b US training 18.41d
IVC stenosis 12.22e FOCUS exam 15.2h 16.14ace Pneumothorax 17.13d US training 18.41d
Ao dissection Stanford Asc Ao aneurysm.4a Abdominal aorta branches Pneumothorax 17.13d
type A 12.23a Asc Ao aneurysm 15.4b 16.14bdf Pneumothorax 17.14 Appendix
Ao dissection Stanford Asc Ao aneurysm 15.4c IVC 16.15b Paracentesis 17.16a Antero posterior view CT
type A 12.23c RV Dysfunction 15.5a IVC 16.15c Paracentesis 17.16b Transverse plane view CT
Air embolism 12.24a RV Dysfunction 15.5g IVC 16.15d Paracentesis 17.16c CT Sagittal plane view CT
Embolus 12.25a RV Dysfunction 15.5e HVF 16.16a Paracentesis 17.17 Mid-Esophageal Four-
Pleural Effusion 15.6a HVF 16.16b Chamber A1
Chapter 13 Pleural Effusion 15.6c PVF 16.17b Chapter 18 Mid-Esophageal Two-
TCCS 13.3a RV Dysfunction 15.10a Bladder 16.18a Central line kit 18.3 Chamber Mitral
TCCS 13.3c RV Dysfunction 15.10c Stomach 16.20a Internal jugular vein 18.4 Commissural A2
Temporal windows 13.7 RV Dysfunction 15.10e Stomach 16.20a Internal jugular vein 18.9a Mid-Esophageal Two-
Orbital window 13.8b RV dysfunction Free fluid 16.21a Internal jugular vein 18.9b Chamber A3
Occipital window 13.9 and pulmonary Free fluid 16.21c Internal jugular vein 18.9b Mid-Esophageal Long-Axis
Vasospasm 13.11a hypertension 15.12a Subdiaphragmatic abscess Internal jugular vein 18.9c A4
Vasospasm 13.11c IVC Diameter 15.13a 16.22a Internal jugular vein 18.9d Mid-Esophageal Left Atrial
Papilledema 13.16a IVC Diameter 15.13b Rectosigmoid free fluid Internal jugular vein Appendage A5
Optic nerve examination Respiratory variation of 16.23a 18.10a Mid-Esophageal Left Atrial
13.17c the SVC 15.14a Retroperitoneal Internal jugular vein Appendage A5
Postcraniotomy 13.21b Cardiac tamponade 15.15a hemorrhage 16.24a 18.10b Mid-Esophageal Right
Cerebral hematoma 13.22a Pleural Effusion 15.16a Abnormal kidneys 16.25c Internal jugular vein Ventricular Outflow
Cerebral hematoma 13.22b Pleural Effusion 15.16c Ileus 16.26a 18.10c Tract A6
Shunts and emboli 13.25f Pleural Effusion 15.16d Full stomach 16.27a Internal jugular vein Mid-Esophageal Right
Submandibular window Thrombus 15.17a Full stomach 16.27b 18.10d Ventricular Outflow
13.10ab Thrombus 15.17b Full stomach 16.27d Double tip sign 18.11a Tract A6
Submandibular window Ventricular Septal Defect Air in the liver 16.28a Double tip sign 18.11a Mid-Esophageal Bicaval A7
13.10cd 15.18a Air in the liver 16.28c Double tip sign 18.11b Mid-Esophageal Aortic
Ventricular Septal Defect Abdominal Ao aneurysm Guidewire position 18.12a Valve Short-Axis A8
Chapter 14 15.18b 16.29a Guidewire position 18.12c Mid-Esophageal Aortic
Anatomic correlation 14.2a Myxoma 15.19a Abdominal Ao aneurysm Guidewire malpositions Valve Short-Axis A8
Anatomic correlation 14.2a Myxoma 15.19b 16.29d 18.13b Mid-Esophageal Aortic
Anatomic correlation 14.2b Pulmonary Embolism Ao dissection 16.30a Guidewire malpositions Valve Long-Axis A9
Anatomic correlation 14.2c 15.20a Ao dissection 16.30b 18.13c Mid-Esophageal Ascending
Anatomic correlation 14.2c Pulmonary Embolism IVC 16.31a US of axillary vasculature Aortic Short-Axis A10
Normal lung sliding 15.20b IVC 16.31b 18.15b Mid-Esophageal Ascending
14.5a & b Ao Dissection 15.21a IVC 16.31c US of axillary vasculature Aortic Long-Axis A11
Lung pulse 14.6c Ao Dissection 15.21b IVC 16.31c 18.15c Transgastric Mid-Papillary
US settings and B lines Takotsubo syndrome IVC 16.31e Axillary vein 18.16a Short-Axis B1
14.12a 15.22a IVC 16.31f Axillary vein 18.16b Transgastric Basal Short-
US settings and B lines Takotsubo syndrome Abnormal portal vein vel Enhanced needle 18.17 Axis B2
14.12b 15.22b 16.32a Femoral vessel Transgastric Basal Short-
US settings and B lines Outflow Tract Obstruction Gallstone complications examination 18.20a Axis B2
14.12c 15.23a 16.33a Femoral vessel Transgastric Two-Chamber
US settings and B lines Outflow Tract Obstruction Abnormal gallbladder examination 18.20c B3
14.12d 15.23c 16.34c Femoral vessel Transgastric Long-Axis B4
E and Z lines 14.13a Outflow Tract Obstruction Hydronephosis 16.35e examination 18.20d Transgastric Right
E and Z lines 14.13b 15.23e Foley catheter 16.36a Complications 18.21a Ventricle B5
Subcutaneous emphysema LVOT obstruction 15.24a Foley catheter 16.36b Complications 18.21b Transgastric Inferior Vena
14.14a LVOT obstruction 15.24a Foley catheter 16.36c Complications 18.21b Cava Long-Axis B6
Congestive heart failure Acute colitis 16.37a Complications 18.21c Transgastric Inferior Vena
14.16b Chapter 16 Acute colitis 16.37b Complications 18.22a Cava Long-Axis B6
Congestive heart failure Abdominal wall varices Abnormal liver 16.38c Complications 18.22c Deep Transgastric C1
14.16c 16.2a Abnormal spleen 16.39a Complications 18.22d Descending Aortic Short-
Congestive heart failure Abdominal wall varices Abnormal spleen 16.39c Complications 18.23b Axis D1
14.16e 16.2b Complications 18.23c Descending Aortic Long-
Congestive heart failure Normal liver anatomy 16.6 Chapter 17 Complications 18.24a Axis D2
14.16g Right posterior axillary Internal Mammary Artery Complications 18.24c Upper Esophageal Aortic
Air bronchogram 14.20a coronal upper and mid 17.1a Complications 18.24d Long-Axis E1
Viral pneumonia 14.21a abdominal US views Internal Mammary Artery US-guided examination Upper Esophageal Aortic
Viral pneumonia 14.21b 16.7bdf 17.1b of the upper extremity Short-Axis E2
Pulmonary venous Right posterior axillary Effusions 17.3d 18.27

xxiv
 PART I
Chapter 1
Ultrasound Imaging:
Acquisition and Optimization
Wilfredo Puentes and Annette Vegas

INTRODUCTION Sound Waves

This chapter presents a brief description of the basic
physical principles of ultrasound (US), as well as the steps
involved in producing an ultrasound image. Common US
probes and key controls on the US machine for acquiring
and optimizing the different imaging modes (two-dimen-
sional (2D) and Doppler) are outlined.
BASIC PRINCIPLES OF ULTRASOUND
Sonography comes from the Latin sonus (meaning “sound”)
and the Greek word graphien (meaning “to write”). Medical
ultrasonography uses high frequency sound waves to create
images. To appreciate how this process occurs, it is import-
ant to understand some of the concepts related to sound.
Sound is mechanical energy transmitted as longitudinal
pressure waves formed by molecular interaction in a
medium, and hence cannot occur in a vacuum. As sound
waves travel through a medium, each molecule hits an-
other and returns to its original position, creating more
dense (compression) and less dense (rarefaction) regions
in the medium. Different properties of the sound wave
can be described including: cycle, frequency, period,
wavelength, amplitude, power, intensity, and propaga-
tion speed (Figure 1.1).
A cycle comprises one rarefaction and one compression
of the sound wave. Frequency (f) is the number of cycles
in a given time, 1 cycle/second = 1 Hertz (Hz). Period (T)
is the time it takes for one complete cycle to pass a point
or for a wave to travel a distance of one wavelength.

Wavelength (λ) Fig. 1.1 Properties of sound waves and

A pulses. (A) Sound wave cycle descriptors
Amplitude
include period (T), wavelength (λ),
Period
amplitude and frequency (f) as shown for
ƒ = 2 Hz
waves of 2 Hz and 4 Hz frequencies. (B) A
pulse is a collection of sound wave cycles
with characteristics of pulse duration
1 cycle (PD), pulse repetition period (PRP), spatial
pulse length (SPL) and pulse repetition
frequency (PRF).
ƒ = 4 Hz

PD Listening
SPL
time PRF = 4

PRP

Time 1 Second

1
2 Basic Transesophageal and Critical Care Ultrasound
Wavelength (λ) represents the horizontal distance between
any two successive equivalent points on the wave or the
length of one cycle of the wave. Frequency and period are
inversely proportional (f = 1/T), thus a higher frequency
has a shorter wavelength and period. For instance, a high-
er frequency probe, such as a transesophageal echocardio-
graphy (TEE) probe, is superior to a transthoracic echocar-
diography (TTE) probe in detecting endocarditis because
small vegetations can be missed with TTE. The TTE probe
has a lower frequency and consequently a larger and less
precise wavelength.
Amplitude (A), power (P) and intensity are strength
measurements of the sound wave. All share similar prop-
erties as these measurements are: (1) determined by the
source, (2) changed by adjusting power on the US machine,
and (3) decrease in value from attenuation as US propagates
in the body. Amplitude is the difference in maximum and
mean values of wave height as measured in decibels (dB).
The P refers to the rate of energy transfer, as measured in
watts (W) or Joules (J). Intensity (Intensity = P/area) is the
concentration of energy in a sound beam or the amount
of power per unit of area, as measured in W/cm2. Intensity
establishes the mechanical and thermal bioeffects of US
on tissue. Spatial peak temporal average (SPTA) intensity
relates to tissue heating and should be <720 mW/cm2 with
clinical imaging to avoid damaging tissues.
Propagation speed is the distance the sound wave
travels through a medium per second (distance per time).
It is how fast the disturbance is passed from molecule to
molecule. Speed depends solely on the medium’s properties
of stiffness and density. It is slowest through gases, faster
through liquids, and fastest through solids. In so tissue,
the propagation speed is equal to 1540 m/s (1.54 mm/µsec).
Propagation speed (c) is the product of frequency and wave-
length (c = f λ).
Sound Pulses
Ultrasound systems produce short bursts of sound, called
“pulses”. A pulse is a collection of sound cycles that travel
together. Analogous to the properties of sound waves there
are several terms that describe pulsed waves (Figure 1.1):
pulse duration (PD), spatial pulse length (SPL), pulse rep-
etition frequency (PRF), pulse repetition period (PRP), and
duty factor (DF).
The PD is the amount of time to complete a single pulse.
Pulse repetition period is the amount of time from the
beginning of one pulse to the beginning of the next pulse;
it includes the pulse duration and listening time. Pulse rep-
etition frequency is the number of pulses per second; this
is reciprocal to pulse repetition period (PRF = 1/PRP). Pulse
repetition frequency is important as it affects temporal
resolution and also determines the Nyquist limit in Doppler
US. In clinical US, the duty factor (DF % = PD/PRP) is the ratio
of time that the transducer produces a pulse or is switched
on. On average, the transducer is listening 99% of the time,
and emitting the US signal for less than 1%, so the normal
DF is 0.1–1%. Listening time depends on the distance that
the sound wave needs to travel to find the object of inter-
est, longer distances or greater depth means a longer time
listening.
By definition, US has a frequency greater than 20,000
cycles per second (20,000 Hz or 20 KHz). The human audible
range is between 20 and 20,000 Hz. For medical diagnosis,
US frequency is measured in millions of cycles per second
(MHz). Most medical imaging transducers have a frequency
range of 2–15 MHz, although some special intravascular US
(IVUS) and US biomicroscopy of the eye uses frequencies as
high as 60 MHz.
BEHAVIOR OF SOUND IN THE BODY
Understanding how sound waves behave in the body is
important for optimizing and interpreting US images. An
ultrasound probe generates a sound beam that is meant
to travel through the body in a straight line. Most of the
initial US beam is lost (attenuation), some continues further
on (transmitted) and some returns back to the transducer
(reflected). Differences at the tissue interfaces (type, size,
and shape) and the angle of beam incidence determines the
behavior of sound in the body.
Attenuation refers to loss of US beam energy (−dB) as
it travels through tissue (Figure 1.2A). Absorption (Figure
1.2B) is the primary cause of attenuation (80%) as sound
is converted to another energy form, such as heat. Reflec-
tion, refraction (Figure 1.2C), and scattering (Figure 1.2D)
also contribute to attenuation. Attenuation exponentially
increases with depth and linearly increases with the US
frequency. Higher frequency sound has greater absorption
and scattering, and thus poorer penetration. The attenua-
tion coefficient (AC) correlates attenuation with frequency
(AC = 0.5 × f or f/2) where f is measured in MHz.
Half power distance or half value layer thickness (HVLT)
expresses the amount of attenuation of US in tissues. It is
equal to the distance that US travels in particular tissues
before the energy or amplitude decreases to half its original
value. It is expressed by HVLT = 3/AC. The normal range in
clinical practice is 0.25–1.0 cm (Table 1.1).
Acoustic impedance is the resistance of different tissues
to the passage of sound that is a characteristic of only the
tissue. It cannot be measured but is calculated as: imped-
ance in Rayls (Z) = density (kg/m3) × propagation speed
(m/s). Impedance increases when density increases and/
or propagation speed increases, thus it is highest for bone
and lowest for air (Table 1.1). Air is almost impermeable to
US and this makes it difficult to image air-filled structures,
like the lungs, trachea, bronchus and bowel. Most of the
US energy is reflected and the rest is absorbed, impeding
visualization of the structures localized behind the air. The
transducer–skin interface illustrates important principles of
acoustic impedance and sound transmission. The transducer
surface is constructed with material of similar impedance
to skin (matching layer) and the use of gel improves the
 Ultrasound Imaging: Acquisition and Optimization 3

AA B
B Absorption CC DD Scattering

Reflection
Amplitude

Refraction

Distance

Fig. 1.2 Attenuation. (A) There is a decrease in amplitude (−dB) as a sound wave travels. (B–D) Attenuation may be from absorption,
complete or partial reflection, refraction, and scattering of the initial sound signal.

surface contact by eliminating air, to permit better sound STEPS IN PRODUCING AN ULTRASOUND
transmission. IMAGE
At an interface between two tissues, the differences
in acoustic impedance of each tissue determines the per- Creating an ultrasound image requires equipment that
centage of the incident US beam that is reflected back. The will emit, transmit and process returning sound waves
greater the acoustic mismatch, the greater the amount of into information on a display. Central to this process is the
sound that is reflected. The amount reflected is expressed US transducer, which must convert electrical signals into
using the Intensity Reflection Coefficient (IRC) or Reflection US, emit the sound beam for brief periods (microseconds),
Coefficient, as calculated from the known impedances (Z1 receive returning sound signals and convert these back into
and Z2) between interfaces (Figure 1.3). No reflection will electrical signals for display. Processing of returning sound
occur if the two tissues have identical impedance, allowing determines how it will be displayed. Manipulation of US
the whole sound wave to be transmitted. The relatively machine knobs allows for optimization of the image display.
small differences in acoustic impedance in so tissue allow
the US beam to travel further and image deeper structures
(Table 1.1).
In addition, the angle of incidence and the size and shape
of tissue at the interface influences sound wave behavior. Table 1.1 Attenuation for Different Tissue Interfaces (for a
Complete reflection occurs when the angle of incidence is frequency of 2 MHz)
90° (normal incidence) and results in optimal 2D imaging
(Figure 1.2C). At other angles of incidence, only partial Medium Half power Attenuation Impedance
return of the sound beam occurs, the remainder is transmit- distances (Rayls)
ted, but oen with a slight deflection in angle (refraction) (cm)
(Figure 1.2C). Thus imaging structures at oblique angles
Water 380 Extremely 1.48
may result in suboptimal images from an incomplete return
low
of the US signal and can cause artifacts from refraction.
Scattering is redirection of sound in multiple directions Blood, urine 15 Low 1.65
that is caused by irregularities of the tissue interface (Fig-
Soft tissues 1–5 Low 1.63
ure 1.2D). This occurs when sound interacts with structures (not muscle)
much smaller than the transmitted wavelength, resulting
in the absorption of US followed by its re-emission in all Muscle 0.6–1.0 High 1.71
directions. Scattered echoes originate from the boundary Bone 0.0–0.7 Higher than 7.8
between small, weakly reflective, irregular-shaped objects muscle
and these are less angle dependent and less intense. These
echoes produce the smaller amplitude, homogeneous pat- Air 0.08 Extremely 0.0004
tern of the tissues of many internal structures (liver, muscle). high
4 Basic Transesophageal and Critical Care Ultrasound

Incident
Z1
Reflected
Z1 _ Z2
IRC (%) = ×100
Transmitted Z2 Z1 + Z2

Fig. 1.3 Reflection. With normal angle (90°) of incidence, reflection depends on the difference in impedances (Z1 and Z2) between
the mediums. A small reflection will occur if there is a slight difference in impedance. A large reflection will occur if the impedances
are substantially different as determined by the intensity reflection coefficient (IRC).

Transducers Ultrasound Probe

A transducer is any device able to convert one form of
energy into another. Ultrasound transducers convert
electrical energy into acoustic energy and vice versa. The
piezoelectric effect describes the ability of certain materi-
als (quartz, ceramics, lithium sulfate, and others) to create
voltages with mechanical deformation. When a voltage is
applied to a piezoelectric material (reverse piezoelectric ef-
fect), it expands and contracts, changing shape to generate
mechanical impulses (compressions and refractions) in the
form of sound waves (Figure 1.4). Piezoelectric material or
the ceramic (barium titanate, lead zirconate titanate) is a
primary component of US transducers.
A medical US probe is comprised of several common compo-
nents that are arranged differently depending on the type
of probe (Figure 1.5).
1. Piezoelectric element or ceramic generates acoustic
pulses and electrical signals when submitted to
electrical or mechanical stimulation. The collection and
arrangement of active elements (crystals) in a single
transducer is the array.
2. Electrodes transmit the electric current to and from
the piezoelectric element and records the voltage
generated by the returning echoes.

-
Reverse
piezoelectric effect
Voltage

+
Tissue

Piezoelectric effect

Fig. 1.4 Piezoelectric effect. An electrical voltage is applied to the crystals in the ultrasound probe, causing them to vibrate,
creating sound pulses that are emitted by the probe (reverse piezoelectric effect). Returning sound pulses (echoes) reflect back
causing the crystals to vibrate again (piezoelectric effect), now creating an electrical voltage (V) difference, which is processed to
the final image displayed on the screen.
Another random document with
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 So they waxed rich and happy, and there never was a time when a
man was hungry that he did not have some good things to eat, and it
very seldom happened that any of these hard workers found himself
without an appetite at meal-time.
For people who work hard and well are very apt to have all they
want and to want all they have. If they do not want it to use
themselves, they want it to sell or give away.
So, in time the people of this country became not only very
comfortable but very wealthy.
They had great barns full of grain and vast stores of everything
needful for their use and livelihood, and as they often sold their
surplus productions to other nations, they had great vaults full of
money.
But they all worked away every day, just the same as they used to,
because they were so accustomed to toil, that they would not have
been happy without work.
So, of course, they became richer and richer, and jollier and jollier
until at last they became so prosperous and happy that other nations
began to take notice of them. It was rather unusual, in those days to
see a whole nation so jolly.
The people in the adjoining countries were by no means so happy
and prosperous. Most of them were much better pleased with
fighting than with work, and it, therefore, often happened that they
were hungry when there was very little to eat.
For war is a very bad thing for crops. It is sometimes as injurious
as a long drought. For somebody must plant and hoe or there will be
little to eat in a land, and if the people spend most of their time in
warfare there cannot be much agricultural work going on.
But these outside people, especially those who lived in the land of
Voldor to the north of the country of the Cabordmen, had an idea that
it was a great deal easier to make war and capture supplies than to
raise crops themselves.
 This is why, after having carefully watched the Cabordmen for
some years, and noting their great possessions, they resolved to
make war upon these industrious and jolly people.
So they gathered together an army, which was an easy thing for
them to do, and invaded the country of the Cabordmen.
Our jolly friends were much astounded and distressed when the
great army of the Voldorites marched over their borders.

THE VOLDORITES MARCH INTO THE COUNTRY OF THE

CABORDMEN.
Now the poor Cabordmen knew not what to do. They were not
soldiers, and, indeed, there was not so much as a single sword or
spear or shield in the whole country. They never had gone to war
and they were not prepared for it, nor did they know anything about
fighting. It was altogether a new business to them.
 They gathered together and held hasty consultations, but they
could decide upon no plan to repel the invaders. What could they—a
nation of simple, jolly husbandmen—do against a great army of well
armed and practised warriors?
There seemed to be nothing left for them but to surrender at once,
and let the Voldorites help themselves to whatever they wanted. In
this case the poor Cabordmen and their families would not only be
stripped of every thing, but it was very likely indeed that the invaders
would carry off many of them as prisoners, and take them to Voldor,
and make them cultivate the land of their captors.
This was terrible to think of. But they could devise no plan to
escape this dreadful fate.
The Voldorites were now encamped upon the northern edge of
their territory, which was yet uninhabited and barren. The enemy so
far had met with none of the Cabordmen, but many of the latter had
seen the great army from afar without having made themselves
visible.
Night came on while the people were in this fearful condition of
fear and suspense. Less than a day’s march would bring the fierce
enemy into their midst. No one went to bed, for who could sleep at
such a time? No fires or lamps were lighted. They all gathered
together by the faint light of the new moon, and bewailed their sad
condition.
There was only one person among them who seemed to have
retained his courage and thoughtfulness. This was a young man
named Adar Gan Ip.
He was named Adar because he was a painter. Ip was his family
name, and he was called Gan after his grandfather. He was the only
painter in the whole nation, and he had learned his trade in a
neighboring country, where he had been to sell grain.
He principally painted signs and portraits. He did not paint many
portraits, because the people had but little time to sit for them, but he
painted a good many signs on barns and granaries. People liked to
have their names on their barns. He had no paint but one pot of
white paint. So when he painted portraits he painted only old men,
so that the white paint would do for their hair and beards as well as
for their faces. Having no colored paint for eyes, he always painted
portraits with the faces turned around, so that the eyes could not be
seen.
This young man was, as I have said, the only person among the
Cabordmen who seemed to have his wits about him.
He conceived a plan of safety, and lost no time in putting it in
execution.
The Cabordmen placed great confidence in him because of the
excellence of his portraits, and so when he told them his plan—or
that part of it which they were to carry out—they agreed to it at once.
What they were to do was very simple; each person was to take
two days’ provision, and to clear out of the country, every man,
woman, and child of them. They were to march away as fast as they
could over the south border, and to stay there until they heard from
Adar Ip. They were to take nothing with them but their two days’
provision and the clothes they wore, which were generally scanty, as
the climate was mild, and were to leave their houses and fields, and
everything just as they were at that time. Doors all open, and
everything lying where it had been last used.
So up got every man, woman and child, took food for two days,
and departed, leaving Adar Ip behind. They were all great walkers,
being so accustomed to activity in the field, and before morning they
had all passed out of sight over the south border of the land.
Then with his pot of white paint in one hand, and his brush in the
other, went Adar Ip, at the first peep of day, to the grave-yards of the
Cabordmen. There were three of these, not very far from the centre
of their country, which was a small country as you may well imagine.
The Cabordmen, being very healthy, seldom died of any disease
but old age; and there were not very many persons buried in the
three grave yards. In the first, and largest, there were seventy-two
graves; in the second, forty-one, and the third, a new one, only
thirteen. The graves were all leveled and sodded over, so that the
surface of the grave yard seemed like a beautiful lawn.
In one enclosure were the grandfathers, in another the
grandmothers, and in the third the very old maids and bachelors who
had died. There were no grave-stones or anything of the kind, but at
the gate of each enclosure was a board, stating how many persons
were buried therein. Every time it was necessary, which was very
seldom, Adar Ip painted out the old number on the board and put in
a new one.
When our young painter reached the first grave yard he quickly
painted three ciphers after the figures on the board by the gate. Then
running to the second enclosure he painted a three and two ciphers
on that board, and on the third, he painted a six and a five and a four
after the figures that were already there. Then he hurried away and
hid himself.
In the course of the morning the Voldorite army reached the
settlements of the Cabordmen. They did not stop long at the first
houses, but hurried on, carefully looking out on every side for some
sign of resistance from the people. But they saw no such sign, and
they saw no people. This naturally surprised them very much. And
the farther they went the more they were surprised.
At last the leaders ordered a halt, and gathered together for
consultation.
“I cannot imagine,” said the chief, “what this means. We must look
out for some ambush or trap. By the way, has any one seen any of
these Cabordmen?”
Careful inquiries were made, but no one had seen a Cabordman
since they had entered the country,
“This is indeed remarkable,” said the chief of the Voldorites. “I
cannot imagine what it means. No ambush has been discovered, no
fortifications, no people. The houses are all open. Everything seems
as if no enemy were expected. All their valuables are here. Where
are they?”
 Nobody knew, but just then a man who had been in the vicinity of
the grave-yards came running to the place where the officers were
gathered together, and he urged them to come back with him and
see what he had seen.
They all followed him, and when they saw the boards at the
entrance of the enclosures they were utterly astounded.
“What!” cried the chief, walking from one enclosure to another,
“Here lie buried seventy-two thousand Cabordmen, and here forty-
one thousand and three hundred Cabordwomen, and here thirteen
thousand, six hundred and fifty-four unmarried Cabordmen and
women! Comrades, we have found them! The whole nation lies
buried here!”
A deep silence fell upon the group of officers, and upon the vast
body of soldiers that had gathered around them.
At length the chief spoke again:
“It must have been a terrible pestilence,” he said. “The whole
nation lies buried here. I have added up these figures. I know there
were not more than one hundred and twenty-six thousand nine
hundred and fifty-four of them all put together. They are all dead and
buried here. It must have been awful!”
Some of the officers and soldiers then began to whisper together.
Then some one said out loud that this must be a dreadfully
unhealthy country. Then some of them began to move away as if
they were going to the rear to attend to something important in that
direction. Then the chief mounted his horse and rode away, and in
ten minutes that whole army made up its mind that it would be
exceedingly imprudent to remain any longer in such an
unwholesome country, and away they all marched towards Voldor.
The farther they went the more frightened they became, and soon
a perfect panic pervaded the army, and they set off at the top of their
speed, horsemen and footmen for their own barren but salubrious
land.
 THE FLIGHT OF THE VOLDORITES.

Away they went over the hills and the plains, and in two hours
there was not a Voldorite in the land of the Cabordmen.
Then uprose Adar Ip, and fled towards the southern border to
inform his countrymen of their happy deliverance.
They all returned quickly and found everything as it had been left.
Nothing had been taken, for none of the invaders wanted anything
that had been in a land where such a terrible mortality had prevailed.
Great was the joy and great the gratitude exhibited towards the
ingenious young Ip. The people presented him with a well filled
granary, and ordered him to paint on its walls at the public expense,
the history of his exploit.
“I wonder,” said one old man, “who they thought buried all these
people, if everybody was dead.”
 “I don’t know,” said Adar Ip. “But I think that they had such a high
opinion of the industry and prudence of our people that they
supposed we had doubtless made suitable arrangements for a
contingency of this kind.”
After this, the Cabordmen were never again disturbed, and they
became jollier than ever.
 Transcriber’s Notes

pg 257 Changed: shelter of the Esquimax snow houses

to: shelter of the Esquimaux snow houses
pg 272 Changed: The small volcanes are more active
to: The small volcanoes are more active
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