Echocardiography:

general principles and examples

Andreea Catarina Popescu MD, PhD

 Ultrasounds (US)

- When meeting a border

between two structures the
ultrasound is partially
reflected, partially
transmitted.
- Reflection depends on
- difference in tissues
impedance
- atenuation, reflection,
scattering
- The angle of incidence
- Penetration is better at lower
frecquency
- Resolution is better at
higher frecquency
 Echo techniques

M-mode
2D
Doppler
pulsed wave Doppler,
continuous
color
Tissue Doppler imaging
Speckle tracking
3D
 Advantages

accessible

repeatable

non-invasive

cost-effective
 Limitations

Operator dependent
Frequent indications for echocardiography

Left ventricular ejection fraction (LVEF)

Grade III systolic murmurs
HTN – end organ damage
Chest pain
Dyspnea
Hemodynamic instability
Sources of emboli
Aortic dissection
Syncope
 What kind of information do we get?
Morphological: dimensions,
defects,
masses (eg vegetation, trombi, tumors)
Motion/syncronism

Function LV, RV ejection fraction

Hemodynamic: gradients,
estimated pressures

Prognostic indices: LVEF, LVESD,

LVESV, MAPSE. WMSI
M mode echocardiography

Eur J
Echocardiogr
2001;Vol 2
Feigenbaum’s Echocardiography, 2005. Lippincott Williams & Wilkins.
 M-mode echocardiography

Standardized measurements

Time resolution

anatomic M-mode

color M-mode
M-mode measurements
Functional importance of the long axis
dynamics of the human left ventricle

Jones CJH, et al. Br Heart J 1990;63:215-20.

 MAPSE

Alam M, et al. J Am Soc Echocardiogr 1992;5:427-432.

MAPSE
Mitral annular plane
systolic excursion
 TAPSE

Hammarstrom E, et al. J Am Soc Echocardiogr 1991;4:131-138.

 Pathophysiological insights
into the mechanism of regurgitation

Schwammenthal E, et al. Circulation 1994;90:307-322.

 Standard examination

Suprasternal
Right parasternal
Parasternal

Apical

Subcostal
2D standard echocardiography views
Parasternal
long axis (plax)
short axis (sax)
great vessels
mitral valve
medioventricular
apex
right ventricle (RV) inflow
Apical 4 chambers (c)
2c
3c
5c

Subcostal long axis

short axis
Suprasternal
 Parasternal long axis
• 3rd/ 4th/ 5th left parasternal space, transducer marker to
patient right clavicula
 Parasternal long axis
• LV – anterior septum, posterior wall , LV outflow tract
• aortic valve – 2 cusps out of 3 – the anterior one is the right
cusp, the posterior is either the noncoronary or the left
• ascending aorta
• RV – anterior wall
Parasternal short axis view
great vessels
Parasternal short axis view
great vessels
Parasternal short axis view
mitral valve level
Parasternal short axis view
papillary muscles level
- LV – wall motion
- papillary muscles – medial and
lateral
- RV
Parasternal short axis view apex
 Long axis view of the RV inflow

RV
ATV

RA
PTV
Long axis view of the RV outflow
Apical 4c

LA left atrium
LV left ventricle
Raright atrium
RV right ventricle
MV mitral valve
AT tricuspid valve
Apical 4c
Apical 5c

RV LV

Ao
RA LA
Apical 2c
Apical 3c
Subcostal 4c
Subcostal sax
Suprasternal

Left
Brachioce common
phalic a carotid

Left
subclavi
an artery

Right
Ascending PA Descending
aorta aorta
 Doppler effect
 Johann Christian Doppler 1842

- The engine sound of a moving train

is heard different by a person in a
resting train, depending on its
velocity and direction of moving.
 Blood flow pattern
Laminar flow
– flow in parallel rows, same direction, almost same
velocity – predominant in heart and blood vessels
– flow velocity is maximum in the middle and lower
near the vessel wall
 Blood flow pattern
Turbulent
• disruption of normal flow pattern, vortices, different
velocities and directions
• Characteristic for stenosis
• high velocities
 Doppler echocardiography
 based on frecquency change of reflectated wave
compared with transmitted wave
 the change of frecquency is determined by
interaction of emitted wave with the front wave
dcause by the moving blood cells
 Doppler echocardiography
The frecquency of reflected wave is getting higher if
the blood cells are moving towards the transducer
and is getting lower if the blood cells are moving
away from the transducer
 Doppler equation
Doppler shift (Fd) (returned frecquency) of ultrasound will
depend on both the transmitted frequency (fo)
and the velocity (V) of the moving blood. The velocity
of sound in blood is constant (c) and is an
important part of the Doppler equation.
 Doppler equation

Main application in echocardiography – measurement

of the Velocity of blood flow
 Important

For minimum error the angle between the US

beamand the direction of blood flow should be
near to 0 (these two to be parallel).

In 2D echo to get the best accuracy the US

beam has to be perpendicular to the structure.
 CW Doppler

Continuous generation of US waves and continuous

reception
 CW Doppler
- Advantage:
- Able to determine high velocities (abnormal
velocities into the heart measure more than 1,5-
2m/s)
- Disadvantage:
- No spatial resolution, it gets the information from
all the points on the direction of the transmitted
beam

- Application gradients, maximum velocities

 PW Doppler

Pulsed wave (PW) Doppler systems use a

transducer that alternates transmission and
reception of ultrasound.
 PW Doppler

Advantage
- ability to provide Doppler shift data selectively from
a small segment along the ultrasound beam,
referred to as the “sample volume”. The location of
the sample volume is operator controlled.e
Disadvantage
- Can not measure higher velocities (>1,5m/s),
aliasing is appearing

Application flow debit

CW aortic valve
LVOT PW Doppler
 Mitral inflow PW Doppler

E – early filling
A – atrial contraction

Unda Unda
E A

Unda
Pulmonary valve PW Doppler
 CW Doppler

Measure gradients – estimate pressure

- grade valve stenosis

transvalvular gradient = 4v12- 4v22

V1 = v max velocity determined by CW Doppler

V2 = velocity determined by PW Doppler, proximal to stenosis

usually V2 <1m/s so

Gradient = 4vmax2
 Color Doppler

 PW Doppler application
 Red blood flow towards the transducer
 Blue – blood flow away from the transducer
 Visualisation of flow, guide for PW, CW
 Semiquantitative analysis of regurgitant leasions
 Abnormal flows
 Color Doppler plax
aortic and mitral valve
PW Doppler Tissue Doppler
Speckle tracking echocardiography

Longitudinal and radial deformationon

30 strain
[%]
20 radial
strain
10

0
longitudinal
- strain
10 AVO AVC MVO MVC
-
20 ECG
LONG

RADIAL

CIRCUMF
Myocarditis – conventional echo follow-up
32 y/o woman with heart failure
22 Dec 2009 7 Jan 2010 3 Feb 2010
Myocarditis - speckle tracking echo follow-up
32 y/o woman with heart failure
22 Dec 2009 7 Jan 2010 3 Feb 2010

GLS= -7.8% GLS= -14.3% GLS= -19.4%

NYHA IV NYHA III NYHA II

3D bicuspid valve
3D echo atrial view of
myxomatous MV
3D echo flail P2
3D echo ASD view from LA
Amplatzer occluder
 Emergency dep echocardiography
Chest pain

dyspnea

hemodynamic instability

syncope

POCUS problem oriented cardiac ultrasound

FOCUS
 Echocardiography
Positive and differential diagnosis in

heart failure

Myocardial infarction

Valvular heart disease

Pericarditis

Cardiomyopathy

Congenital heart disease

Valvular prosthesis
 Valvular heart disease
Regurgitant lesions
color Doppler jet width
regurgitant oriffice area

Valvular stenosis
2D, aria planimetry
gradient mean, maximum
functional area

The effects on LV, RV, pulmonary hypertension

Mitral stenosis
Mitral stenosis
Mitral stenosis

Severity
• mean gradient
• MVA (mitral valve area) planimetry, PHT

MVA Mean gradient

Normal : 4-6 cm2
mild: < 5 mmHg
mild: 1,6 – 2 cm2
moderate: 5-10 mmHg
moderate: 1 – 1,5 cm2
severe : > 10 mmHg
severe : < 1 cm2
Mitral stenosis
Mitral stenosis
 associated lesions
- mitral regurgitation
- aortic stenosis, tricuspid rheumatic disease
Mitral stenosis
 effects
- LA enlargment
- pulmonary hypertension
- RV function
Aortic stenosis
CW Doppler Severe Aortic Stenosis
CW Doppler Aortic Stenosis CW Doppler HOCM
Aortic stenosis
Echocardiography
 grade
- maximum velocity v max
- mean gradient
- aortic valve area AVA

AVA Mean gradient

Normal : 2,5 – 3,5 cm2 mild : < 20 (30) mmHg
mild: 1,6 – 2 cm2 moderate : 20-40 (30-50) mmHg
moderate AS: 1 – 1,5 cm2 severe : > 40 (50) mmHg
severe : < 1 cm2
Aortic stenosis
Effects
- LV hypertrophy
- LV systolic and diastolic function
- pulmonary pressure
Mitral regurgitation

rheumatismal
Mitral regurgitation

MV prolapse
Mitral regurgitation

ischemic
Mitral regurgitation

congenital (cleft AMV)

Aortic regurgitation
Aortic regurgitation
 Pulmonary hypertension
Colour Doppler tricuspid regurgitation jet

CW Tricuspid Regurgitation jet

RV-RA gradient (from TR regurgitation jet) =
4 x (tricuspid regurgitation velocity)2

PAPs = PRV = RV-RA gradient+ RAP

PAPs = 112 + 15 = 127 mmHg

RAP estimated by inferior vena cava

dimensions and response to inspiration
Pulmonary hypertension indirect signs
Dilated RV, D shaped LV, interatrial septum bulges to left atrium

Notch on descending
slope of pulmonary artery flow
Pulmonary hypertension
 Myocardial infarction

Diagnostic criteria
new wall motion abnormality
 WMSI
1 normokinezia,
2 hypokinezia
Lang et al. 3 akinezia
4 diskinezia or
aneurysm

Lang et al. Recommendations for Cardiac Chamber Quantification

by Echocardiography in Adults: An Update from the American Society of
Echocardiography and the European Association of Cardiovascular Imaging
European Heart Journal – Cardiovascular Imaging (2015) 16, 233–271
Lang RM, et al Recommendations for chamber quantification
Eur J Echocardiogr 2006 7, 79-108
Lang et al. Recommendations for Cardiac Chamber Quantification
by Echocardiography in Adults: An Update from the American Society of
Echocardiography and the European Association of Cardiovascular Imaging
European Heart Journal – Cardiovascular Imaging (2015) 16, 233–271
Wall motion abnormalities
Ischemic heart disease
Ischemic heart disease

LV aneurysm with thrombus

STEMI complication

IVS rupture
 Cardiomyopathies

 CM – dilated, hypertrophic, restrictive

 Echocardiography:
 diagnosis
 LV, RV fx, Hemodynamic effects
 prognostic
 Treatment monitoring
 Dilated cardiomyopathy

Hipertrophic cardiomyopathy
Restrictive cardiomyopathy
Pericardial disease
• Pericarditis
- Pericardial effusion
- Tamponade
- Constrictive pericarditis
- Effusive constrictive pericarditis
Pericardial effusion
Tamponade
Constrictive Pericarditis
Constrictive Pericarditis
 LV systolic function

• LVEF
• LV ESV (end-systolic volume)
• MAPSE
• LVOT VTI; Stroke volume
• dP/dt
• WMSI
 Measurement of
LV volumes and LVEF
Simpson’s

• LVEF >45-50%
• LVEDVi <97 ml/m2
• LVESVi <49 ml/m2

ASE/EAE 2005
Eur J Echocardiogr 2006;7:79-108
LVEF=(295-281)/295
= 5%
 3D echo for LV volumes and EF
Whenever possible it is
preferable to use 3D echo

• Better accuracy than 2D

• Lower variability
• Validated against CMR
PW Doppler LVOT SV (stroke volume)
 Mitral flow pattern PW Doppler
Impaired Restrictive
relaxation Normal

E
A

DT Adur

E<A E>A E >> A

EDT > 240 EDT 140 - 240 EDT < 140
IVRT > 100 IVRT 70 - 90 IVRT 60 - 90
PW mitral flow
E/A ratio increases with filling pressure

E/A ratio Relaxation Filling pressure

very good very, very bad

restrictive filling

good pseudonormal

bad
impaired relaxation

Disease severity
Echocardiography - prognostic role

Heart failure LVEF, E/Vp, Tei

Myocardial infarction LVEF, LVSV

Valvular heart disease v max Ao

Cardiomyopathy LVmass

Congenital disease
 Ischemic stressors and protocols
Exercise Dypiridamole
Dobutamine Adenosine
Pacing
reveal ↓ CFR

increase O2 demand reduce O2 supply

“horizontal steal / vertical steal”

CAD CAD
Microvascular disease
(HT, DZ)

Wall motion Wall motion Without wall motion

abnormalities abnormalities abnormalities
Type of response in dobutamine echo
Normal response
Normal response
Ischemic response
Stress echocardiography
Dynamic mitral regurgitation
Coronary angiography – left anterior descending proximal stenosis
 Myocardial perfusion

Slow replenishment of
myocardial microbubbles
during low power imaging
following a transient
increase in acoustic power
(flash imaging) can indicate
decreased perfusion.

Improved de identification of ischemia as compared with wall motion

assessment alone

Limitations: is a time-consuming technique requiring extensive training

 Transesophageal echocardiography

Main indications
sources of embolism
aortic dissection
suspicion of endocarditis
Evaluation of mitral valve (mechanism of regurgitation)
Congenital defects (ASD atrial septal defect)

Intraoperatory evaluation
intracardiac shunts
mitral valve prolapse / regurgitation
Aortic and mitral valve endocarditis
Spontaneous contrast and thrombi in left atrium in
a patient with mitral stenosis
Foramen ovale patent with evidence of right to left
shunt
3D echo atrial view of
myxomatous MV
Aortic dissection
Severe atherosclerotic lesions of thoracic descending aorta
 Descending aorta dissection

Dissection flap

True
lumen
False lumen
 Echocardiography

Valuable tool for

• Diagnosis

• Prognosis

• Evaluation of complications

• Evaluation of the effects of therapies

 Echocardiography

Well trained operator

Complete exam

FOCUS exam