LINICAL APPLICATION OF ECHOCARDIOGRAPHY

Dr STELLA COOKEY
Cookey S.N
* Echocardiography (echo or echocardiogram) is an ultrasound
test that uses high-frequency sound waves(3.5 to 7.5mHz) to
produce an image of the heart. The sound waves are sent
through a device called a transducer(probe) and are reflected off
the various structures of the heart. These echoes are converted
into pictures of the heart that can be seen on a video monitor.
* Humans stop hearing sound when the frequency is higher than
20kHz
* Ultrasound uses frequency greater than 20mHz
* The higher the sound the lesser the penetration depth but a
higher the resolution.
* Name the different types of Echocardiogram.
* Know how a Transthoracic Echocardiogram is performed.
* Define the four main parameters that are needed to set up a
standard echocardiogram laboratory and understand their
functionality.
* Name and identify the different modalities and views and what
they are used for.
* Define the main echo chambers
* Understand parameters of systolic function and diastolic
functions
* State the indications of an Echocardiogram
* Be able to perform Level 1 Echocardiogram.

*Objectives
* Transthoracic Echocardiogram
* Transesophageal Echocardiogram
* Stress Echocardiogram
Exercise stress echocardiogram
Pharmacological
* Contrast Echocardiogram
Saline
Definity

* Types of Echocardiogram
* M-Mode
* 2-D
* 3-D
* Doppler
Spectral Doppler
Colour Doppler
Tissue Doppler(tissue velocity and tissue doppler)
Power Doppler

*Modalities Of Echocardiogram
Is a cut section of the heart showing the
structure in relation to the movement of the
heart during the cardiac cycle.
M-mode recordings permit measurement of
cardiac dimensions and motion patterns.
It comes handy in assessing chamber size
and wall functions.

* M-Mode echocardiography
This allows real tme imaging of structures and
motion of the heart structures.
Ultrasound is transmitted along several scan
lines(90-120), over a wide arc(about 900) and many
times per second.
The combination of reflected ultrasound signals
builds up an image on the display screen.
A 2-D echo view appears cone-shaped on the
monitor.
* Two-Dimensional Echo
(2-D echo)
 * Doppler echocardiography
Doppler echocardiography is a method for
detecting the direction and velocity of moving
blood within the heart. Different modalities are
employed.
Spectral
Pulsed Wave (PW) useful for low velocity flow
e.g. MV flow
Continuous Wave (CW) useful for high velocity
flow e.g aortic stenosis
Color Flow
(CF)(BART RULE) Different colors are used to
designate the direction of blood flow. red is flow
toward, and blue is flow away from the
transducer with turbulent flow shown as a mosaic
pattern.
*Tissue Doppler
* http://en.wikipedia.org/wiki/Echocardiograph
y

*3D
*Cardiac anatomy
Transducer position: left sternal edge;
2nd – 4th intercostal space
Marker dot direction: points towards
right shoulder
Most echo studies begin with this view
It sets the stage for subsequent echo
views

*Parasternal Long-Axis View

Many structures seen from this view

(PLAX)
Transducer position: left sternal edge; 2nd
– 4th intercostal space
Marker dot direction: points towards left
shoulder(900 clockwise from PLAX view)
By tilting transducer on an axis between
the left hip and right shoulder, short axis
views are obtained at different levels,
from the aorta to the LV apex.
Many structures seen
* Parasternal Short Axis
View (PSAX)
PSAX at the level of the
papillary muscles showing
how the respective LV
segments are identified,
usually for the purposes of
describing abnormal LV wall
motion
LV wall thickness can also be
assessed

* Papillary Muscle (PM)level

*Apical 4-Chamber View (AP4CH)
Transducer position: apex of
heart
Marker dot direction: points
towards left shoulder
The AP5CH view is obtained
from this view by slight
anterior angulation of the
transducer towards the chest
wall. The LVOT can then be
visualised
The AP5CH view is obtained from this
view by slight anterior angulation of the
transducer towards the chest wall. The
LVOT can then be visualised

*Apical -5-chamber
view
 *Apical 2-Chamber View
(AP2CH)
Transducer position: apex of the
heart
Marker dot direction: points
towards left side of neck (450
anticlockwise from AP4CH view)
Good for assessment of
LV anterior wall
LV inferior wall
 * Sub–Costal 4 Chamber
View(SC4CH)
Transducer position: under the xiphisternum
Marker dot position: points towards left
shoulder
The subject lies supine with head slightly low
(no pillow). With feet on the bed, the knees
are slightly elevated
Better images are obtained with the abdomen
relaxed and during inspiration
Interatrial septum, pericardial effusion, desc
abdominal aorta
Transducer position: suprasternal notch
Marker dot direction: points towards left jaw
The subject lies supine with the neck
hyperexrended. The head is rotated slightly
towards the left
The position of arms or legs and the phase
of respiration have no bearing on this echo
window
Arch of aorta

*Suprasternal View
 Echo Chambers Valves
* LV * MV
* RV * TV
* LA * AV
* RA
* Pv
* LVOT
* RVOT
Walls * VESSELS
LV * PT
RV * AORTA
LA * PULMONARY VEINS
RA * SVC/IVC
* Class I: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful and
effective.
* Class II: Conditions for which there is conflicting evidence and/or
a divergence of opinion about the usefulness/efficacy of a
procedure or treatment.
* IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
* IIb: Usefulness/efficacy is less well established by
evidence/opinion.
* Class III: Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful/effective
and in some cases may be harmful.

*INDICATIONS
* Chamber size
* Hypertrohy
* Systolic function
* Diastolic function

* Systemic Hypertension.
* Define the primary lesion and its etiology and
judge its severity.
* Define hemodynamics.
* Detect coexisting abnormalities.
* Detect lesions secondary to the primary lesion.
* Evaluate cardiac size and function.
* Establish a reference point for future
observations.
* Reevaluate the patient after an intervention.

*MURMURS
*  hypertrophic cardiomyopathy,
* valvular aortic stenosis,
* aortic dissection, pericarditis,
* MVP, and acute pulmonary embolism, produce
distinctive .

*Chest Pain
* regional wall motion abnormality
* Assess severity
* Prognosis
* Give treatment modality
* Assessment of complication
Acute mitral regurgitation
Infarct expansion and LV remodeling
Ventricular septal rupture. 
Free wall rupture
Intracardiac thrombus
 RV infarction
Pericardial effusion
Post interventional procedure re-ealuation

*Ischeamic Heart Dx
* Cardiomyopathy and Assessment of Left
Ventricular Function:
* Echocardiographic Parameters:
* M-mode is mostly used for a normal shaped LV
* 2D and Volumes for n abnormally shaped LV
* Cardiomyopathies
* Dyspnoea and Edema
* Rv evaluation
* CCF

*LV Function
* Pericardial effusion
* Tamponade
* Constrictive Pericarditis
* Congenital absence of the Pericardium

*Pericardial DX
* primary tumors of the heart, such as atrial
myxoma,
* metastatic disease from extracardiac primary
sites,
* thrombi within any of the four chambers, and
vegetations (infectious or noninfectious) on any
of the four cardiac valves.

* Cardiac masses and tumours

* Aortic aneurysm
* Aortic Dissection
* Degenerative Aorti valve Dx

*  Diseases of the Great Vessels

* Pulmonary hypertension
* Pulmonary thromboembolism

*Pulmonary
* Shunt defects
* Structural abnormalities, Pel ebstein anomaly
* Abnormal AV connections
* Abormal Fistulas

*Congenital Heart Dx.

* Assess LV functions * Both;
* Systolic function: EF, FS
* Diastolic function
* 1. TEI index
* Cardiac Output
1. Mitral inflow velocities(E/A)
2. Mitral annular velocities
3. Ratio of E/E´
4. Deceleration time
5. Isovolumetric relaxation
time

Systemic Hypertension
* Source of embolus.
* Risk of re-occurence

* Neurologic and other cardio-

embolic diseases.
* Underlying cause of the dx
* Hemodynamic consequence of the arrythmias

* Arrhythmias and Palpitation

* >48hrs you require a TEE .

* Cardioversion in a Person
with AF
* Trauma to exclude tamponade
* Sepsis to exclude cardiogenic shock

*Critically ill
* Pre-op evaluation,hypertensives.arrythmias.
* Fulfills the criteria for routine check-ups

It is non invasive
It is readily available

*Screening
* Fetal Echocardiography.
Transvaginal probe,
12-14 wks
* Pediatric Echocardiography.

* Other Echocardiography
* Cardio diagnostics is growing rapidly in the world, as
cardiovascular events tops the chart as the leading cause of
death globally (2011) 17.9 million deaths, greater than TB
and HIV put together.. approx. 8.0million deaths.
* We are behind!!! The choice to understand cardio
diagnostics is one that will reduce the embarrassment you
will face as a medic practicing In the Nigeria, Africa and
the World.
* Level 1 Echocardiography is recommended for the attending
physician in an ICU setting, Emergency room much more for
a family Physician and an Internal medicine doctor.

*Conclusion.