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 Anita Sadeghpour
Azin Alizadehasl
Editors

Case-Based Textbook
of Echocardiography

123
Case-Based Textbook of Echocardiography
Anita Sadeghpour • Azin Alizadehasl
Editors

Case-Based Textbook of
Echocardiography
Editors
Anita Sadeghpour, MD, FACC, FASE
Rajaie Cardiovascular, Medical and Research
Center, Echocardiography Research Center
Iran University of Medical Sciences
Tehran
Iran
Azin Alizadehasl, MD, FACC, FASE
Rajaie Cardiovascular, Medical and Research
Center, Echocardiography Research Center
Iran University of Medical Sciences
Tehran
Iran

ISBN 978-3-319-67689-0    ISBN 978-3-319-67691-3 (eBook)

https://doi.org/10.1007/978-3-319-67691-3

Library of Congress Control Number: 2017960827

© Springer International Publishing AG, part of Springer Nature 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
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Preface

Echocardiography is the most frequently used imaging modality for the evaluation of all car-
diovascular diseases in that it can provide precise information regarding the heart’s structure,
function, and hemodynamic abnormalities. However, it requires a high level of knowledge,
capability, and expertise in ultrasound physics, anatomy, physiology, and also clinical cardiol-
ogy, and it also requires one to carry out a substantial number of echocardiography studies in
order to attain and maintain the practice skills.
For all the excellent textbooks and reviews on echocardiography, we felt the need for a step-
by-step educational textbook covering basic to advanced echocardiography besides focusing
on practical points in real cases and latest published guidelines.
It is noteworthy to mention that each chapter can serve as an overview for introduction to
the subject and subsequently as a concise review of echocardiography, and questions at the end
of each chapter will provide a useful method of self-assessment.
We hope that this book will be an ideal companion to all cardiovascular imagers and cardi-
ologists by covering all that is required in echocardiography training. The compilation of this
book would not have become possible without the contributions of our indefatigable expert
editors, who wrote their respective chapters. Needless to say, our work comes with its short-
comings and we look forward to addressing them with the aid of your valuable comments.

Tehran, Iran Anita Sadeghpour

Tehran, Iran Azin Alizadehasl

v
Acknowledgments

We dedicate this book to our mentors, patients, and dear families. Numerous individuals have
made invaluable contributions to the compilation of Case-Based Textbook of Echocardiography,
particularly our expert contributors, who wrote their respective chapters and shared their expe-
riences and cases from around the world.
Many other individuals have also contributed directly and indirectly to the conclusion of this
volume with their extensive experience in various fields, and we hereby especially appreciate
the efforts of our colleagues in Rajaie Cardiovascular Medical and Research Center including
Marzieh Pakbaz, Farshad Amouzadeh, Mahdieh Azimi, Shahnaz Sheikh, and Solmaz Jafari.
Finally, we give special recognition to the publisher, Springer, for its unwavering moral and
technical support and inspiration throughout the project. Our friends at Springer, not least
Grant Weston, Evanjalin Hephsibah, and Ramamoorthy Jeyashree, deserve considerable
appreciation for their kindness and helpfulness in accommodating our numerous requests.

vii
Contents

1 Basic Principles of Echocardiography �������������������������������������������������������������������    1

Anita Sadeghpour and Azin Alizadehasl
2 Transthoracic Echocardiography, Standard Windows
and Echocardiographic Views���������������������������������������������������������������������������������   15
Anita Sadeghpour, Azin Alizadehasl, and Maryam Forouzesh
3 Transesophageal Echocardiography�����������������������������������������������������������������������   29
Azin Alizadehasl, Anita Sadeghpour, and Fahimeh Khesali
4 Sedation for Transesophageal Echocardiography�������������������������������������������������   47
Rasoul Azarfarin and Ramin Rohanifar
5 Basic of 3D Echocardiography; Clinical Use in Daily Practice ���������������������������   53
Ahmad S. Omran
6 Basic Principles of Fetal Echocardiography�����������������������������������������������������������   71
Mahmood Ebrahimi
7 Handheld Echocardiography�����������������������������������������������������������������������������������   79
Dominika Filipiak-Strzecka, Piotr Lipiec, and Jarosław D. Kasprzak
8 Artifacts and Pitfalls of Echocardiography�����������������������������������������������������������   87
Anita Sadeghpour and Azin Alizadehasl
9 Contrast Echocardiography�������������������������������������������������������������������������������������   97
Farimah Aminian and Harald Becher
10 Summary of Cardiac Chamber Quantification in Adults
by Echocardiography����������������������������������������������������������������������������������������������� 109
Nehzat Akiash
11 Echocardiography Evaluation of Left Ventricular Systolic Function,
Systolic Dysfunction, and Ventricular Dyssynchrony������������������������������������������� 127
Nehzat Akiash, Azin Alizadehasl, and Anita Sadeghpour
12 Echocardiographic Assessment of Myocardial Mechanics:
Velocity, Strain, Strain Rate and Torsion��������������������������������������������������������������� 141
Hoorak Poorzand, Anita Sadeghpour, Azin Alizadehasl, and Samir Saha
13 Echocardiographic Evaluation of the Diastolic Function and Dysfunction ������� 169
Anita Sadeghpour, Azin Alizadehasl, and Samaneh Pourhosseinali
14 Echocardiographic Evaluation of the Right Heart ����������������������������������������������� 185
L. Rudski and J. Deschamps
15 How to Assess the Left and Right Atria in Clinical Practice ������������������������������� 205
Piotr Lipiec and Jarosław D. Kasprzak

ix
x Contents

16 Echocardiography in Hypertension ����������������������������������������������������������������������� 211

Azin Alizadehasl and Anita Sadeghpour
17 Echocardiographic Assessment of Native Valvular Heart Disease����������������������� 217
Anita Sadeghpour and Azin Alizadehasl
18 Echocardiography in Prosthetic Heart Valves������������������������������������������������������� 239
Anita Sadeghpour and Azin Alizadehasl
19 Infective Endocarditis����������������������������������������������������������������������������������������������� 255
Trine K. Lauridsen and Anna Lisa Crowley
20 Pericardial Diseases ������������������������������������������������������������������������������������������������� 267
Michael Chetrit and Vartan Mardigyan
21 Dilated Cardiomyopathy and Myocarditis������������������������������������������������������������� 279
Azin Alizadehasl and Anita Sadeghpour
22 Hypertrophic Cardiomyopathy������������������������������������������������������������������������������� 287
Anita Sadeghpour and Azin Alizadehasl
23 Restrictive Cardiomyopathy ����������������������������������������������������������������������������������� 299
Azin Alizadehasl and Anita Sadeghpour
24 Unclassified Cardiomyopathies: Arrhythmogenic Right Ventricular
Dysplasia/Cardiomyopathy (ARVD/C) and Left Ventricular
Non-Compaction Cardiomyopathy (LVNC)����������������������������������������������������������� 305
Anita Sadeghpour and Azin Alizadehasl
25 Echocardiography in Coronary Artery Disease
and Acute Myocardial Infarction ��������������������������������������������������������������������������� 315
Azin Alizadehasl and Anita Sadeghpour
26 Echocardiographic Assessment of Coronary Blood Flow������������������������������������� 323
Jarosław D. Kasprzak, Piotr Lipiec, and Karina Wierzbowska-Drabik
27 Stress Echocardiography����������������������������������������������������������������������������������������� 333
Anita Sadeghpour and Azin Alizadehasl
28 Echocardiography in Patients with Adult Congenital Heart Disease ����������������� 343
Anita Sadeghpour and Azin Alizadehasl
29 Perioperative Transesophageal Echocardiography����������������������������������������������� 379
Anita Sadeghpour and Azin Alizadehasl
30 The Role of Echocardiography in Mitral Valve Repair����������������������������������������� 393
Nishant K. Sekaran, Alina Nicoara, and Zainab Samad
31 Intraprocedural Transesophageal Echocardiography������������������������������������������� 413
Devin W. Kehl, Florian Rader, and Robert J. Siegel
32 Echocardiography in the Critical Care Unit ��������������������������������������������������������� 423
Anita Sadeghpour and Azin Alizadehasl
33 Echocardiography and Pulmonary Hypertension������������������������������������������������� 431
Maude Limoges and Lawrence Rudski
34 Echocardiography in Heart Transplantation��������������������������������������������������������� 445
Nehzat Akiash, Anita Sadeghpour, and Azin Alizadehasl
35 Echocardiography in Patients with Ventricular Assist Devices ��������������������������� 453
Anita Sadeghpour and Azin Alizadehasl
Contents xi

36 Cardiac Masses and Tumors����������������������������������������������������������������������������������� 459

Azin Alizadehasl and Anita Sadeghpour
37 Evaluation of Cardiac Sources of Emboli by Echocardiography������������������������� 467
Azin Alizadehasl and Anita Sadeghpour
38 Disease of the Aorta ������������������������������������������������������������������������������������������������� 477
Azin Alizadehasl and Anita Sadeghpour
39 Role of Echocardiography in Arrhythmia������������������������������������������������������������� 489
Azin Alizadehasl and Anita Sadeghpour
40 Echocardiography in Systemic Diseases����������������������������������������������������������������� 499
Azin Alizadehasl and Anita Sadeghpour
41 Echocardiography in End-Stage Renal Disease����������������������������������������������������� 503
Azin Alizadehasl and Anita Sadeghpour
42 Echocardiography in Pregnancy����������������������������������������������������������������������������� 507
Atousa Mostafavi
43 Echocardiography in Trauma��������������������������������������������������������������������������������� 515
Azin Alizadehasl and Anita Sadeghpour
44 Aging Changes in Echocardiography��������������������������������������������������������������������� 519
Paulina Wejner-Mik, Piotr Lipiec, and Jarosław D. Kasprzak
45 Echocardiography in Obesity ��������������������������������������������������������������������������������� 525
Karina Wierzbowska-Drabik and Jarosław D. Kasprzak
46 Full Schematic Echocardiographic Formulas and Points������������������������������������� 537
Azin Alizadehasl and Anita Sadeghpour

Index����������������������������������������������������������������������������������������������������������������������������������� 565
Abbreviations

2D Two-dimensional
2DE Two-dimensional echocardiography
3D Three-dimensional
3DE Three-dimensional echocardiography
4C Four chamber
A Peak velocity of the mitral (or tricuspid) valve atrial wave inflow (cm/s)
A.Ao Ascending aorta
A′ TDI of the mitral annulus
a′ Peak velocity of the mitral (or tricuspid) annulus atrial phase motion (cm/s)
AA Ascending aorta
ACC American College of Cardiology
ACCF Appropriateness criteria of the American College Of Cardiology Foundation
AF Atrial fibrillation
AHA American Heart Association
AIDS Acquired immune deficiency syndrome
AL PM Anterolateral papillary muscle
ALC Anterolateral commissure
AMI Acute myocardial infarction
AML Anterior mitral leaflet
AO Aorta
AoV Aortic valve
AP2 Apical 2-chamber
AP3 Apical 3-chamber
AP4 Apical 4-chamber
APS Antiphospholipid syndrome
AR Pulmonary valve atrial reversal
ARVD/C Arrhythmogenic right ventricular dysplasia/cardiomyopathy
AS Aortic stenosis
ASA American Society of Anesthesiologists
ASC Ascending
ASD Atrial septal defect
ASE American Society of Echocardiography
ASH Asymmetric septal hypertrophy
AT Acceleration time
ATMV Accessory tissue mitral valve
ATRAMI Autonomic tone and reflexes after myocardial infarction
AUC Appropriate use criteria
AV Aortic valve
AVA Aortic valve area
AVF Arteriovenous fistula
AVR Aortic valve replacement
AVSD AV septal defect

xiii
xiv Abbreviations

AZ Azygos
BAAT Biatrial anastomosis technique
BBB Bundle branch block
BCAT Bicaval anastomosis technique
BIS Bispectral index
BMI Body mass index
BMPR2 Bone morphogenetic protein receptor type 2
BP Blood pressure
BSA Body surface area
CABG Coronary artery bypass graft surgery
CAD Coronary artery disease
CATs Calcified amorphous tumors
CAV Cardiac allograft vasculopathy
CCTGA Congenitally corrected transposition of the great arteries
CE Cardiac echinococcosis
CFI Color flow imaging
CFR Coronary flow reserve
CFVR Coronary flow velocity reserve
CHD Congenital heart disease
CHFpEF CHF with preserved EF
CHFrEF CHF with reduced EF
CMR Cardiac magnetic resonance
CO Cardiac output
COA Coarctation
CP Constrictive pericarditis
CPR Cardiopulmonary resuscitation
CRP C-reactive protein
CRT Cardiac resynchronization therapy
CS Coronary sinus
CSA Cross-sectional area
CT Computed tomography
CTED Chronic thromboembolic disease
CTEPH Chronic thromboembolic pulmonary hypertension
CV Cardiovascular
CW Continuous wave
CX Circumflex branch of the left coronary artery
D Diameter
DA Ductus arteriosus
DC Direct cardioversion
DCM Dilated cardiomyopathy
DD Diastolic dysfunction
DF Diastolic function
DILV Double inlet left ventricle
DORV Double outlet right ventricle
DPG Diastolic pressure gradient
DSE Dobutamine stress echocardiography
DT Doppler tissue
DT Deceleration time
d-TGA Complete transposition of the great arteries
DTI Doppler tissue imaging
DVI Doppler velocity index
DVT Deep venous thrombosis
E Peak E-wave velocity of the mitral valve (cm/s)
Abbreviations xv

E′ Tissue Doppler index of the mitral valve annulus

E/A Ratio of early to atrial inflow velocity (respectively mitral or tricuspid)
E/e′ Ratio of early inflow velocity to early annulus velocity (respectively mitral
or tricuspid)
E′ TDI of the mitral annulus
e′ Peak velocity of the mitral (or tricuspid) annulus early phase motion (cm/s)
e′/a′ Ratio of early to atrial phase of annulus velocity (respectively mitral or
tricuspid)
EACVI European Association of Cardiovascular Imaging
EAT Epicardial adipose tissue
EBD Endocardial border delineation
ECG Electrocardiogram
EDV End-diastolic volume
EF Ejection fraction
EI Eccentricity index
EKG Electrocardiogram
EOA Effective orifice area
ERO Effective regurgitant orifice
EROA Effective regurgitant orifice area
ESRD End-stage renal disease
ESV End-systolic volume
ET Ejection time
FA Femoral artery
FAC Fractional area change
FC Functional class
FDA Food and Drug Administration
FED Fibroelastic deficiency
FMR Functional mitral regurgitation
FPS Frame per second
FV Femoral vein
GCS Global circumferential strain
GLS Global longitudinal strain
HAPE High altitude pulmonary edema
HbA1C Glycosylated hemoglobin
HCM Hypertrophic cardiomyopathy
HF Heart failure
HHD Hypertensive heart disease
HIV Human immunodeficiency virus
HOCM Hypertrophic obstructive cardiomyopathy
HPRF High pulse repetition frequency
HR Heart rate
HT Heart transplantation
HTN Hypertension
HU Hunsfiel unit
HV Hepatic vein
HVR High volume rate
I Inversus
IAS Inter-atrial septum
ICA Internal carotid artery
ICD Implantable cardioverter defibrillators
ICU Intensive care unit
Idiopathic RCM Idiopathic restrictive cardiomyopathy
IE Infective endocarditis
xvi Abbreviations

I-I Inner edge–to–inner edge

IL1; 6;16 Interleukin 1, 6;16
IMH Intramural hematoma
IMT Intima-media thickness
INR International normalized ratio
IV Intravenous
IVA Isovolumic acceleration
IVC Inferior vena cava
IVCT Isovolumic contraction time
IVG Intraventricular gradients
IVRT Isovolumic relaxation time
IVS Interventricular septum
IVUS Intravascular ultrasound
JNC Joint national committee
LA Left atrium
LAA Left atrial appendage
LAP Left atrial pressure
LAPV Left upper pulmonary vein
LAV Left atrial volume
LAVI Left atrial volume index
LAX Long axis
LCA Left coronary artery
LCC Left coronary cusp
LDL Low density lipoprotein
LE Lower esophageal
LGE Late gadolinium enhancement
LGE/CMR Late gadolinium enhancement/cardiovascular magnetic resonance
LHC Left-sided heart catheterization
LHD Left heart disease
L-L Leading edge–to–leading edge
LLPV Left lower pulmonary vein
LMCA Left main coronary artery
LPA Left pulmonary artery
LSCA Left subclavian artery
LUPV Left upper pulmonary vein
LV Left ventricular
LV/LA Left ventricular/left atrial
LVAD Left ventricular assist device
LVED Left ventricular end-diastolic
LVEDD Left ventricular end-diastolic dimension
LVEDP Left ventricular end-diastolic pressure
LVEF Left ventricular ejection fraction
LVES Left ventricular end-systolic
LVESD Left ventricular end-systolic dimension
LVH Left ventricular hypertrophy
LVIDd Left ventricular internal diameter
LVM Left ventricular mass
LVNC Left ventricular non-compaction
LVO Left ventricular opacification
LVOT Left ventricular outflow tract
LVOT VTI LVOT subvalvular velocity time integral
MAC Mitral annulus calcification
MADIT-II Multicenter automatic defibrillator implantation trial II
Abbreviations xvii

MB Moderator band
MBF Myocardial blood flow
MCE Myocardial contrast echocardiography
MCSs Mechanical circulatory supports
MDCT Multidetector computed tomography
ME Mid-esophageal
MHz Megahertz
MI Myocardial infarction
M-mode Motion mode
MPA Main pulmonary artery
MPAP Mean pulmonary artery pressure
MPG Mean pressure gradient
MPI Myocardial performance index
MPR Multiplanar reconstruction
MR Mitral regurgitation
MRI Magnetic resonance imaging
MS Mitral stenosis
MTHFR Methylene tetrahydrofolate reductase
MV Mitral valve
MVA Mitral valve area
MVLs Mitral valve leaflets
MVP Mitral valve prolapse
MVR Mitral valve replacement
MVs Myxomatous valves
NAFLD Nonalcoholic fatty liver disease
NCC Noncoronary cusp
NSAID Nonsteroidal anti-inflammatory drug
NSVT Nonsustained ventricular tachycardia
NYHA New York Heart Association
OHT Orthotopic heart transplantation
P Posterior
PA Pulmonary artery
PADP Pulmonary artery diastolic pressure
PAEDP Pulmonary artery end-diastolic pressure
PAH Pulmonary artery hypertension
PAP Pulmonary arterial pressure
PAPVC Partial anomalous pulmonary venous connection
PASP Pulmonary artery systolic pressure
PAT Pericardial adipose tissue
PCWP Pulmonary capillary wedge pressure
PDA Patent ductus arteriosus
PE Pulmonary embolus
PET Positron emission tomography
PFO Patent foramen ovale
PFT Pulmonary function test
PH Pulmonary hypertension
PISA Proximal isovelocity surface area
PLAX Parasternal long axis
PM Papillary muscle
PM PM Posteromedial papillary muscle
PMC Posteromedial commissure
POCUS Point of care ultrasound
PO-TEE Perioperative transesophageal echocardiography
xviii Abbreviations

PPM Prosthesis–Patient mismatch

PR Pulmonary regurgitation
PREDV Pulmonary regurgitation end-diastolic velocity
PRF Pulse repetition frequency
PSAX Parasternal short axis
PSID Pocket size imaging device
PSLAX Parasternal long axis
PTE Pulmonary thromboembolism
PTMC Percutaneous transvenous mitral commissurotomy
PV Pulmonic valve
PV AR Pulmonary valve atrial reversal
PVd(D) Diastolic component of the pulmonary vein
PVR Pulmonary vascular resistance
PVs Pulmonary veins
PVs1 First systolic component of the pulmonary vein
PVs2 Second systolic component of the pulmonary vein
PVT Prosthetic valve thrombosis
PW Pulsed wave
PW Posterior wall
QT QT interval in ECG
RA Rheumatoid arteritis
RA Right atrium/right atrial
RAA Right atrial appendage
RAP Right atrial pressure
RCA Right coronary artery
RCC Right coronary cusp
RCM Cardiomyopathies, restrictive cardiomyopathy
RF Regurgitant fraction
RH Right heart
RHC Right heart catheterization
RIMP Right ventricular index of myocardial performance
RLPV Right lower pulmonary vein
ROI Region of interest
RPA Right pulmonary artery
RUPV Right upper pulmonary vein
RV Right ventricle
RV Regurgitant volume
RV S’ Tissue Doppler index of the tricuspid valve annulus
RVFAC Right ventricular fractional area change
Rvol Regurgitant volume
RVOT Right ventricular outflow tract
RVOT VTI RVOT subvalvular velocity time integral
RVSP Right ventricular systolic pressure
RWM Regional wall motion
RWMA Regional wall motion abnormalities
RWT Relative wall thickness
S Solitus
SAM Systolic anterior motion
SAX Short axis
SCD Sudden cardiac death
SCD-HeFT Sudden cardiac death in heart failure trial
SE Stress echocardiography
SLE Systemic lupus erythematosus
SPAP Systolic pulmonary artery pressure
Abbreviations xix

SR Strain rate
STE Speckle-tracking echocardiography
STEMI ST-segment myocardial infarction
STJ Sinotubular junction
SV Stroke volume
SVC Superior vena cava
TA Tricuspid atresia
TAPSE Tricuspid annular plane systolic excursion
TAPVC Total anomalous pulmonary venous connection
TAR Traumatic aortic rupture
TAVI Transcatheter aortic valve implantation
TAVR Transcatheter aortic valve replacement
TB Tuberous sclerosis
TCO Tricuspid valve opening time
TCO Tricuspid closure-opening time
TDI Tissue Doppler imaging
TEE Transesophageal echocardiography
TFC Task force criteria
TGA Transposition of the great arteries
TNF α Tumor necrosis factor Α
TR Tricuspid regurgitation
TRV Tricuspid regurgitation velocity
TS Tricuspid stenosis
TTE Transthoracic echocardiography
TTR Transthyretin
TV Tricuspid valve
TVI Time velocity integral
TVLs Tricuspid valve leaflets
UCA Ultrasound contrast agent
V Vertebra
V/Q Ventilation–perfusion
VA Ventriculo-arterial
VADs Ventricular assist devices
VC Vena contracta
VHD Valvular heart disease
Vp Velocity propagation
VSD Ventricular septal defect
VTI Velocity time integral
WMSI Wall motion score index
 Basic Principles of Echocardiography
1
Anita Sadeghpour and Azin Alizadehasl

Abstract HPRF High pulse repetition frequency

Echocardiography which is the most commonly used LV Left ventricular
noninvasive cardiac imaging modality is called ultraso- LVOT Left ventricular outflow tract
nography of the heart. It provides real-time images from PRF Pulse repetition frequency
the heart and gives comprehensive information regarding PW Pulsed wave
the cardiac structure, function and the hemodynamic at a SV Stroke volume
relatively inexpensive cost. Echocardiography uses harm- TEE Transesophageal echocardiography
less ultrasound waves (1–10 MHz) to visualize the heart. TTE Transthoracic echocardiography
This book is a practical echocardiography book; none- Vp Velocity propagation
theless, sonographers and clinicians should be familiar VTI Velocity time integral
with the basic physics of ultrasound to obtain better images
and avoid artifacts. In this chapter we tried to point out
some useful data regarding ultrasound Physics, transducer  efinition and General Principles
D
Types, Echocardiography Modes, Tissue Harmonic in Echocardiography
Imaging, Principles of Doppler Echocardiography and
Doppler-Based Hemodynamic Assessment. • Echocardiography is ultrasonography of the heart. It is the
most commonly used noninvasive cardiac imaging modal-
Keywords ity (Fig. 1.1).
Echocardiography · Ultrasonography · Transducer • Echocardiography is unique for the following reasons:
Doppler · Tissue harmonic imaging · Artifact
1. It provides real-time images from the heart.
2. Images can be obtained quickly with the least patient
Abbreviations discomfort.
3. It is designed to be portable and used as a bedside imag-
CFI Color flow imaging ing modality.
CSA Cross-sectional area 4. It gives comprehensive information regarding the cardiac
CW Continuous wave structure and function and the hemodynamic flow at a
D Diameter relatively inexpensive cost.

A. Sadeghpour, MD, FACC, FASE History

Professor of Cardiology, Echocardiography Research Center,
Rajaie Cardiovascular Medical and Research Center,
Iran University of Medical Science, Tehran, Iran
A. Alizadehasl, MD, FACC, FASE (*)
Associate Professor of Cardiology, Echocardiologist,
Echocardiography and Cardiogenetic Research Centers,
Cardio-Oncology Department, Rajaie Cardiovascular Medical
and Research Center, Tehran, Iran
• First record of heart movement captured by using
ultrasound was reported by Edler and Hertz in 1954
[1, 2].
• 2D echocardiography was developed in the mid 1970s. It
quickly established itself as a very useful tool for imaging
the morphology and function of the heart.

© Springer International Publishing AG, part of Springer Nature 2018 1

A. Sadeghpour, A. Alizadehasl (eds.), Case-Based Textbook of Echocardiography,
https://doi.org/10.1007/978-3-319-67691-3_1
2 A. Sadeghpour and A. Alizadehasl

• 2D echocardiography was followed by the development

of Doppler and color Doppler in 1980.
• Although the concept of transesophageal echocardiogra-
phy (TEE) dates backs to 1970s, the common practice of
TEE began in 1987 [3, 4].

Ultrasound Physics

• 2D echocardiography images are produced by the reflec-

tion of ultrasound waves from the cardiac structure.
• Standard transthoracic echocardiography (TTE) com-
prises M-Mode, 2D, and all spectral Doppler study,
which encompasses continuous wave (CW), pulsed wave
(PW), color Doppler, and tissue Doppler imaging
(Fig. 1.2).
• TTE can be complemented by 3D echocardiography,
TEE, and stress echocardiography.
• In all types of echocardiography, image acquisition and
Fig. 1.1 Bedside transthoracic echocardiography on a patient in the interpretation is operator-dependent and needs consider-
left lateral decubitus position
able training and skill.

Fig. 1.2 Transthoracic echocardiography (TTE), showing 2D study (left upper), M-mode study (right upper), PW Doppler study (left lower), and
CW Doppler study (right lower). PW, pulsed wave; CW continuous wave
1 Basic Principles of Echocardiography
Fig. 1.3 Left: Ultrasound waves can be directed and focused in a beam. Right: The beam has the characteristics of refraction and reflection, which
constitute the basics of image production
Ratefaction Compression
1 cycle
Amplitucle
Pressure
0
Wavelength
Propagation
Fig. 1.4 Ultrasound waves are series of sine waves with compression and rarefaction or peaks and troughs
Ultrasound Physics
• Ultrasound uses sound waves with much higher frequen-
cies than the human hearing range. (Humans can hear
sounds at 20–20,000 Hz.)
• Cardiac ultrasound uses harmless ultrasound waves
(1–10 MHz) to visualize the heart.
• Advantage of ultrasound waves in terms of imaging modal-
ity is that these waves can be directed and focused in a beam
and when this beam passes through a medium and encoun-
ters structures with different acoustic properties, it mani-
fests the characteristics of refraction and reflection (Fig. 1.3).
• However, there is a major disadvantage to the ultrasound
beam: It is poorly transmitted through air.
• As ultrasound waves propagate, they attenuate. The
greater the acoustic mismatch, the more the energy
reflected rather than transmitted.
• Sound waves are produced by mechanical vibration and
are graphically depicted as a sine wave with peaks and
troughs or compression and rarefaction (Fig. 1.4).
This book is a practical echocardiography book; nonethe-
less, sonographers and clinicians should be familiar with the
basic physics of ultrasound to obtain better images and avoid
artifacts. Some basic parameters and definitions are provided
below.
Ultrasound waves: Series of sine waves with peaks and
troughs, denoting compression and rarefaction areas.
Cycle: Sum of 1 compression and 1 rarefaction.
3
10 Hz
1 second
5 Hz
Wavelength (λ): Distance between 2 similar points or 1
complete cycle.
Frequency: Number of wavelengths per unit of time,
measured in hertz (number of cycles per second).
Velocity: Speed of the sound wave in a medium. The
ultrasound velocity in soft tissue is 1540 m/s.
• Frequency has an inverse relation with wavelength based
on the following equation:
velocity of the sound wave( V ) = frequency ( f )
´ wavelength ( l )
V = f ´l
• Ultrasound travels in the soft tissue at a relatively constant
velocity (at about 1540 m/s [1.54 m/ms]); consequently,
the wavelength of a 3.0-MHz (3,000,000 cycles/s) trans-
ducer would be λ = V/f. (1.54 divided by 3 is about
0.51 mm.)
• This equation is important since a transducer with a
higher frequency provides a shorter wavelength and
consequently better resolution, but shallower
penetration.
• Transducer frequency can be changed by a thin or thick
chest wall. The common frequency of the transducer for
adults is 2 to 3 MHz to 5 MHz in a thin chest wall and 5
to 7.5 MHz for pediatrics and 3.5 to 7 MHz for TEE
probes.
4 A. Sadeghpour and A. Alizadehasl
Fig. 1.5 Left: Internal
component of an ultrasound
transducer. Middle: Adult
transducer, Right: Non
imaging Doppler dedicated
probe
Backing material
Fig. 1.6 Phased-array
transducers, consisting of a
series of piezoelectric
crystals. Electrical steering
and focusing is done by
adjusting the timing of
excitation
Transducers
• Transducers are devices that can convert 1 form of energy
to another form.
• Curvilinear probes with their small footprints are the most
suitable probes for echocardiography.
• Fundamental components of transducers are piezoelectric
crystals, which are carefully arranged and interconnected.
Indeed, had it not been for the development of piezoelec-
tric crystals, imaging by ultrasound would not have
become possible (Fig. 1.5).
• Piezoelectric crystals have the capability of vibrating dur-
ing alternating electrical currents, which means that elec-
trical signals are transformed to ultrasound waves.
• This transformation occurs oppositely. In other words, as
piezoelectric crystals receive reflected sound energy, they
transform the sound wave (as mechanical energy) to elec-
tric impulses and finally generate images [3–5].
• For clinical implications, the ultrasound beam should be
focused and steered either mechanically or electronically.
• In the modern era, almost all transducers are phased-array
transducers, consisting of a series of piezoelectric crys-
tals. Electrical steering is done by adjusting the timing of
excitation (Fig. 1.6).
• Gel is used on the transducer to facilitate the transmission
of ultrasound from the transducer to the skin and the heart
as ultrasound cannot pass the bone and air.
• Ability to distinguish small objects separately and in
close proximity is called “resolution”. Resolution is cate-
gorized as spatial, temporal, and contrast.
Electrodes
Piezoelectric crystals
1
2
3
4
3
2
1
• Spatial resolution denotes the smallest distance between 2
objects that can be separately differentiated. It is depen-
dent on the wavelength. (Resolution is about half of the
wavelength.) In a transducer with a 2.5-MHz frequency,
the spatial resolution is about 0.3 mm.
• Contrast resolution refers to the ability to distinguish dif-
ferent shades of the gray scale in an image.
• Temporal resolution or the frame rate means the ability to
track a moving object over time.
• Transducer design has an important role in optimal image
acquisition. The transducer should be small to be placed
between the ribs.
Echocardiography Modes
Ultrasound creates an image by sending pulses and then receiv-
ing them. Since the velocity of sound is known, the time and
consequently the distance between the transducer and the image
are calculated and the received data are traditionally displayed
as A mode (amplitude mode), B mode (brightness), and M
mode (motion). Indeed, 2D echocardiographic shows the struc-
ture and function of the heart and Doppler echocardiography is
the mainstay of cardiovascular hemodynamic assessment.
2D Echocardiography
By placing the transducer on the chest, between the ribs, the
phased array transducer sends the ultrasound beam. The beam
is constructed from multiple scan lines and can be focused and
steered electronically. It creates a fan-shaped sector (Fig. 1.7).
1 Basic Principles of Echocardiography
Fig. 1.7 A fan-shaped beam, constructed from multiple scan lines
Given the heart’s motion, 25 images per second is the
minimum number of images needed to obtain a good image
quality.
 imitation of 2D Study
L Principles of Doppler Echocardiography
• Obtaining good image quality in TTE needs optimal
patient window. Sometimes image quality is suboptimal
because of small acoustic windows, obesity, and hyperin-
flated lungs in chronic lung disease and in early postop-
erative cardiothoracic surgery.
• Image quality decreases in 2D imaging due to attenu-
ation. Attenuation denotes a decrease in the intensity
of the ultrasound wave as the beam travels in the tis-
sue. It is caused by absorption, refraction, and
reflection.
• However, there are a few buttons in the setting which help
to optimize 2D images. The buttons enable the operator to
alter the gain, time gain compensation depth, sector width,
and focus.
• 2D echocardiography can provide not only real-time
high-resolution images of the heart but also a framework
for M-mode, Doppler, and color flow imaging (CFI).
5
Tissue Harmonic Imaging
• Tissue harmonic imaging is an echocardiography mode
that can significantly augment image quality.
• Most recent transducers have the capability of tissue har-
monic imaging by using the resonance feature of the
tissue.
• It means that the tissue vibrates in harmonic frequen-
cies when it receives a specific frequency. Therefore,
by sending the ultrasound waves in a wide bandwidth,
the tissue vibrates at multiple frequencies (2F, 3F, 4F,
etc.) of the transmitted frequency. The received fre-
quency is higher than the fundamental frequency,
which enhances the signal-to-noise ratio and decreases
artifacts (Fig. 1.8) [4, 8].
M-Mode Echocardiography
• M-mode echocardiography is a relatively old echocar-
diography mode and is still a part of standard
echocardiography.
• In M-mode echocardiography, a single scan line is sent
from the transducer to the moving heart and yields a repeti-
tive 1D image on the y-axis and time on the x-axis (Fig. 1.9).
• High temporal resolution (at least 1000 lines per second
in comparison to 25 images per second in 2D study) is a
unique feature of the M-mode study and records detailed
motions heart movements.
• 2D–guided M-mode study is derived by placing a cursor
through the heart structure.
• M-mode is used for the measurement of the left ventricu-
lar (LV) size, LV hypertrophy, and LV mass. Also, it can
display subtle heart structure motions in specific cardiac
diseases (Fig. 1.10) [3, 4, 6].
• In 1842, Christian Doppler discovered “the Doppler
effect”, which constitutes the cornerstone of Doppler
echocardiography and the backbone of cardiovascular
hemodynamic study.
• Principle of the Doppler effect is based on the decrease or
increase in the frequency of the sound wave frequency as
it strikes the moving red blood cells. The ultrasound wave,
graphically illustrated as a sine wave, has several param-
eters and definitions.
Doppler effect: This effect is defined as the increment in
sound frequency as the target moves toward the transducer
and the decrease in sound frequency as the target moves away
from the transducer. In a stationary target, both transmitted
and received frequencies will be identical. In the cardiovascu-
lar system, the red blood cells are the moving target.
6 A. Sadeghpour and A. Alizadehasl

Fig. 1.8 Tissue harmonic

imaging mode, sending
ultrasound waves at a
2.5-MHz frequency (F) and
receiving ultrasound waves at Transmitted at 2.5 MHz
a 5-MHz frequency

Received at 5 MHz

Fig. 1.9 Systolic and

diastolic movements of a 1D
slice of the moving heart. RV,
right ventricle; IVS,
interventricular septum; PW,
posterior wall

RV RV

IVS
IVSd IVSs

LV
LVIDd LVIDd

PW PWd PWs

Doppler shift (Δf = f0 - fr): This shift is defined as the
difference between the transmitted (f0) and received (fr)
ultrasound frequencies.
Doppler equation: The frequency shift is associated with
the velocity of the moving target (v), transmitted frequency
(f0), speed of sound (c), and angle between the interrogated
beam and the blood flow (cos ø) (Fig. 1.11). As the speed of
ultrasound in blood (c) and f0 is known, the Doppler shift
depends on v and cos ø:
Df = 2 f 0 ´ v ´ cos ł / c
Doppler equation correlates with the transmitted fre-
quency (f0), received frequency (fr), angle of incidence (cos
ø), and speed of sound (c).
• When the ultrasound beam is parallel to the blood flow, ø
is 0°, the cosine value is 1, and the maximum velocity is
recorded. As ø increases, maximum velocity is progres-
sively underestimated; and beyond 20°, the underestima-
tion becomes significant.
• Blood flow velocity is calculated based on the following
equation:
v = Df ´ c / 2 f 0 ´ cos ł
Spectral analysis, which is a complex process, determines
the Doppler shift and yields information regarding the flow
velocity, direction of the flow (Doppler trace above the base-
line means that the blood flow moves toward the transducer
1 Basic Principles of Echocardiography 7

Fig. 1.10 M-mode study in different heart diseases. Left upper: White Left lower: Systolic anterior motion of the anterior mitral leaflet. Right
arrow shows the early closure of the mitral valve in the setting of acute lower: Plethora of the inferior vena cava and a dilated hepatic vein in
aortic regurgitation. Right upper: M-mode study shows thickened peri- restrictive cardiomyopathy
cardium and septal bounce (arrow head) in constrictive pericarditis.

F0 F0

V
Fr Fr

Fig. 1.11 Basic principle of the Doppler effect as the increase in sound frequency as the target moves toward the transducer and the decrease in
sound frequency as the target moves away from the transducer
8 A. Sadeghpour and A. Alizadehasl

Fig. 1.12 By tracing

pulsed-wave or continuous-­
wave Doppler study, peak
velocity, peak and mean
pressure gradients, and VTI
are automatically calculated.
VTI, velocity time integral

Velocity
Time

and under the baseline means that the blood flow moves
away from the transducer), timing of the flow, and power of
the flow signal.
There are different forms of Doppler imaging [7–9]:
1. CW
2. PW
3. High pulse repetition frequency (HPRF) or multigated
PW Doppler, containing multiple sample volumes
4. Color flow imaging (CFI)
5. Color Doppler M-mode (using M-mode on CFI)
Most common basic types of Doppler imaging are PW
and CW.
Spectral Doppler gives a graph demonstrating velocities
over time (flow velocity in the y-axis and time in the x-axis).
Peak velocities can be measured and by tracing the PW or
CW envelope.
Velocity time integral (VTI) is automatically calculated,
which corresponds to the stroke distance (Fig. 1.12).
Pulsed-Wave Doppler
• In the PW mode, a single crystal sends intermittent bursts
of ultrasound waves and the same crystal waits to receive
the returning signals.
• PW can measure the blood flow velocities from a specific
location in the heart by using the sample volume.
A A
B B
D ?
D
C C
Fig. 1.13 Measurement of a blood flow velocity based on the Doppler
frequency. It needs sampling the wave for at least twice the wave fre-
quency. Left panel: If the flow moves from place A to place C, the blood
should be sampled at point B; otherwise, the direction of the blood is
not clear (right panel)
• Main weakness of PW is aliasing, which means PW can-
not measure high blood flow velocities. The accurate
measurement of a Doppler frequency needs sampling the
wave for at least twice the wave frequency (Fig. 1.13).
The maximum velocity, which can be measured by PW
without the occurrence of aliasing, is called the Nyquist
frequency limit, which is one-half of the pulse repetition
frequency (PRF = the number of pulses transmitted in
each second).
Nyquist frequency limit = PRF / 2
1 Basic Principles of Echocardiography
Fig. 1.14 Left panel: Normal PW study of the mitral inflow. Right
panel: PW study of the mitral valve in the presence of mitral regurgita-
tion with a high MR jet velocity. Aliasing is seen as a cutoff of velocity
Fig. 1.15 CW Doppler study
measures high velocity
tricuspid regurgitation without
aliasing
• When the frequency shift or velocity is higher than the
Nyquist frequency, aliasing occurs. It results in the inabil-
ity of PW Doppler to correctly record velocities more
than 1.5 to 2 m/s (Fig. 1.14).
• Overcoming aliasing and measuring the peak velocity
of high speed flows accurately require the utilization
of CW. Additionally, decreasing the depth can be
useful.
9
and Doppler signal wrap around the baseline: It results in confusion for
accurate peak velocity measurement and flow direction. PW, pulsed
wave; MR, mitral regurgitation
Continuous Wave Doppler
CW Doppler study utilizes a transducer that contains 2 crys-
tals: One of them continuously transmits and the other one
continuously receives the signals.
CW can accurately measure the maximum velocity with-
out the occurrence of aliasing (Fig. 1.15). However, it has the
disadvantage of not recognizing the location of the sampling
10
since all the velocities along the Doppler beam have been
recorded. In the normal heart, most velocities are less than
1.5 m/s and can be measured via PW Doppler.
In pathological conditions with abnormal, high-velocity
blood flows, CW Doppler should be used to obtain the high-
est flow velocity [4, 7].
High Pulse Repetition Frequency (HPRF)
HPRF mode is a combination of PW and CW Doppler modes
that uses multiple sample volumes (additional sample vol-
umes are not in high-velocity areas) along the beam which
increases the Nyquist limit and allowing measuring higher
velocities (Fig. 1.16).
Color Flow Imaging (CFI)
1. CFI is color-coded PW Doppler imaging with the same
strengths and weaknesses as PW Doppler imaging.
2. By convention:
• Flow toward the transducer is displayed in red and away
from the transducer is displayed in blue (blood flow direc-
tion [BART]: blue away and red toward).
• CFI provides a colorized box on real-time 2D imaging
which displays BART and blood flow velocity.
• Color bar at the right side of the image contains 2 basic
colors: red and blue with multiple shades from dark red to
light and dark blue to light blue.
• Aliasing velocity of the color bar should be set at 50 to
70 cm/s.
• Gain of CFI should be adjusted just below the noise.
• Normal blood flow patterns in the heart and great vessels
are laminar flows.
Fig. 1.16 Doppler study in a patient with Aortic stenosis. Left:
Aliasing in PW study (black arrow) Middle: High pulse repetition fre-
quency mode increase the Nyquist limit the main sample volumes is
A. Sadeghpour and A. Alizadehasl
• High velocity and turbulent flow create multiple direc-
tions, and velocities of the blood flow that exceed the
Nyquist limit appear in a mosaic pattern.
• Aliasing velocity of the color bar should be set at 50 to
70 cm/s.
• Lighter shades of each color means higher velocities, and
when the blood velocity exceeds the Nyquist limit, alias-
ing occurs.
• Variance means that the mosaic pattern of the turbulent
flow turns green (Fig. 1.17).
• Aliasing in CFI means that the color is repeatedly inverted
to the opposite color, creating a mosaic pattern.
• When using CFI, the operator can easily recognize an
abnormal flow pattern as a mosaic pattern or green color
when the variance mode is on (Fig. 1.18).
Low to High velocity
Light
Dark
Zero
Dark
Low to High velocity
Light
Fig. 1.17 Color bar in the color flow imaging mode. Left: Different
shades of blue and red colors as lighter shades are assigned to higher
velocities. Middle: Superimposition of variance on the color map.
Right: Low Nyquist limit
placed in high-velocity area. Right: CW Doppler study measures high
velocity without aliasing
1 Basic Principles of Echocardiography
Fig. 1.18 Left panel: Normal flow pattern of the mitral inflow shown as dark red color by color flow imaging (arrow). Right panel: Aliasing and
turbulent flow at the aortic valve level, suggestive of aortic valve stenosis
• CFI is very useful for the diagnosis of an abnormal turbu-
lent flow, which occurs in discrete stenosis, high velocity
regurgitation, or shunt lesions [10, 11].
Color Doppler M-Mode Imaging
• Color Doppler M-mode is achieved by superimposing
CFI on traditional M-mode images.
• It has the advantages of high spatial and temporal resolu-
tion along the interrogated line.
• It helps to determine the duration and precise timing of
the regurgitation flow (Fig. 1.19).
 oppler-Based Hemodynamic Assessment
D peak pressure gradients by using the modified Bernoulli
• Doppler echocardiography is the basis of noninvasive
hemodynamic assessment and measurement of the blood
flow velocity.
• It is noteworthy that Doppler echocardiography measures
blood velocity, not absolute pressure in the chambers,
pressure gradient, or the flow directly.
• Intracardiac pressures, pressure gradients, and stroke vol-
ume (SV) can be estimated based on 2 important equa-
tions: the Bernoulli equation and the continuity equation.
Bernoulli Equation
The blood velocity in the heart is dependent on the pressure
gradient between the chambers; accordingly, based on the
Bernoulli equation and the measurement of the blood veloc-
ity by Doppler shift, the pressure gradient between the 2
chambers (P1-P2 = ΔP) can be estimated (Fig. 1.20).
• Indeed the Bernoulli equation converts the velocity to the
pressure gradient.
11
• Original Bernoulli equation is a complex formula that
encompasses convective acceleration, flow acceleration,
and viscous friction. That is why the following simplified
form has been suggested:
P1 - P 2 ( DP ) = 4 ( V2 2 - V12 )
• Bernoulli equation-based calculated pressure gradi-
ent has been validated by invasive hemodynamic
study.
• In most patients with aortic stenosis, Doppler echocar-
diography provides trans-aortic jet velocity and mean and
equation, which obviates the need for cardiac catheteriza-
tion (Fig. 1.21).
• It is important to know that Doppler echocardiography
measures the maximum instantaneous peak velocity;
consequently, the Bernoulli equation estimates the maxi-
mum instantaneous pressure gradient, which is higher
than the catheter-based measured peak-to-peak gradient
[4, 6, 8].
Continuity Equation
• Based on the concept of the conservation of mass, what-
ever comes into the heart and passes through the valves
should go out from the other heart valve.
• Consequently, in the absence of regurgitation or intracar-
diac shunting, the flow across all the cardiac valves should
be equal.
• Flow across a valve is equal to the product of the flow
velocity and the cross-sectional area (CSA) of the valve:
flow = CSA × velocity
12 A. Sadeghpour and A. Alizadehasl

Fig. 1.19 Color M-mode study in different heart diseases. Left upper: (Vp) of the mitral inflow in a patient with hypertrophic cardiomyopathy
Diastolic mitral regurgitation in acute aortic regurgitation (arrow). Left (Vp slope = 96 cm/s). Right lower: Absence of diastolic flow reversal in
lower (suprasternal view): Holodiastolic flow reversal in severe aortic the abdominal aorta in severe coarctation
regurgitation. Right upper: Measurement of the velocity propagation

• Because the SV across all heart valves is equal, the area

of the stenotic or regurgitant valve can easily be calcu-
lated using the continuity equation formula (Fig. 1.22).
V1 V2 • Flow measurement is accurate when the flow is laminar
P1 P2
and flat. (The blood cells move in the same direction.)
• As the flow velocity varies through the ejection, the inte-
grated velocity during the ejection period, VTI is used to
Fig. 1.20 Pressure gradient (P1-P2) between the 2 chambers, sepa- measure the flow rate.
rated by a stenotic orifice, can be estimated by the Bernoulli eq. P1 and • VTI results from the sum of velocities and is calculated
V1 are the velocity and the pressure at proximal and V2 and P2 are the
velocity and the pressure at distal to the orifice. As V1 is much lower
automatically by tracing the Doppler velocity signal. VTI
than V2, it can be ignored and the equation is further simplified to is equal to the stroke distance. The SV is calculated by
ΔP = 4 V22 multiplying the CSA by VTI.
1 Basic Principles of Echocardiography 13

Fig. 1.21 Based on a

trans-aortic peak velocity
of 5.58 m/s, the maximum
pressure gradient is
calculated as 4V2 = 4
(5.58 × 5.58) = 124 mmHg

TV
• Preferred sites for the measurement of the annulus and the
MV
AV PV CSA are those that do not change significantly in the car-
SV = VTI X Area (πr 2 = 0.785 X D2)

diac cycle such as the left ventricular outflow tract

(LVOT), aortic annulus, mitral annulus, and pulmonic
annulus with an assumed circular annulus.
D

D
D
D

• Aortic annulus diameter (D) is measured in the paraster-

nal long-axis view in early systole (inner to inner edge)
X

from the junction of the aortic valve leaflets with the

X

X
X

AV VTI
MV VTI
Fig. 1.22 Equal stroke volume across all the heart valves
 ommon Rules for Flow Measurements
C it means the sample volume is too close to flow accelera-
• It is important to match the site of the measurement of the
anatomic CSA and the site of velocity recording.
PV VTI
mitral valve and septum.
• Largest diameter of 3 to 5 measurements should be
TV VTI selected.
• For tracing VTI, the outer edge of the dense part of the
spectral tracing should be traced.
• Usually 3 to 5 cardiac cycles in sinus rhythm and 5 to
10 cycles in atrial fibrillation should be averaged.
• Opening click of the aortic valve should not be seen since
tion, whereas the closing click of the aortic valve is often
seen (Fig. 1.23).

Stroke volume ( SV ) = CSA ´ VTI = pr 2´ VTI = 0.785 ´ D2 ´ VTI

Commonly the LVOT is used for the measurement of the AVarea ´ AVVTI = 0.785 ´ D2 ´ VTI ( LVOT )
SV and the stenotic valve area.
0.785 ´ D2 ´ VTI ( LVOT )
A1 ´ VTI1 = A 2 ´ VTI 2 AVarea =
AVVTI
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