CAR_Basic_Echocardiology ULTRASONIDO CARDI

CONCEPTOS GENERALES DE ECOCARDIORAFIA

1. 1
Echocardiography

2. 2
Content
1. Cardiology
1) Cardiac basic terms & anatomy
2. Echocardiographic Techniques & Evaluation
1) B -mode image
2) M-mode image
3) Color doppler
4) PW & CW doppler

3. 3
1. Cardiology
Cardiac basic terms
& anatomy

4. 4
Cardiac medical Basic term
•Diastole : the passive rhythmical expansion or dilation of
the cavities of the heart during which they fill with
blood compare
•Systole : the contraction of the heart by which the blood is
forced onward and the circulation kept up compare
•Ejection Fraction :the ratio of the volume of blood the heart
empties during systole to the volume of blood in the
heart at the end of diastole expressed as a percentage
normally between 56 and 78 percent

5. 5
Cardiac medical Basic term
•Regurgitation : the backward flow of blood through a defective
heart valve
AR (AorticRegurgitation): leakage of blood from the aorta
back into the left ventricle during diastole because of
failure of an aortic valve to close properly
•MR (MitralRegurgitation)
•TR (TricuspidRegurgitation)
•Embolism :the sudden obstruction of a blood vessel by
an embolus

6. 6
Cardiac medical Basic term
•Stenosis : a narrowing or constriction of the diameter of
a bodily passage or orifice
•AS (Aortic Stenosis ) :a condition usu. the result of disease in
which the aorta and esp. its orifice is abnormally narrow
•MS(Mitral Stenosis): a condition usu. the result of disease in
which the mitral valve is abnormally narrow
•PS(Pulmonary Stenosis): abnormal narrowing of the orifice
between the pulmonary artery and the right ventricle

7. 7
Cardiac medical Basic term & Anatomy
RV Right Ventricle
LV Left VentricleTV Tricuspid Valve
RA Right Atrium
LA Left Atrium
Ao Aorta
MV Mitral Valve
PA Pulmonary Artery
PV Pulmonary Valve
AV Aortic Valve
Septum

8. 8
Cardiac medical Basic term & Anatomy
Colonary Artery
Endocardium
Mayocardium
Pericardium
Epicardium

9. 9
Cardiac Pressure
120/80 mmHg
25/10mmHg
10mmHg
0-5mmHg
25/5mmHg
120/10mmHg

10. 10
2. Echocardiographic
Techniques & Evaluation

11. 11
B-mode
•Cardiac Anatomy Direct Evaluation
•Assessment of Heart Shape & Size & Symmetry
•Cardiac Movement
•Cardiac volumes : LV/LA/RV/RA
•Effusion
•Mass :
Endocardium, Mayocardium, Epicardium, Pericardium
Clinical Applications of B-mode

12. 12
B-mode Techniques & Evaluation
Cardiac window
1.Parasternal window
2. Apical window
3. Subcostal window
4. Suprasternal window
3
2
1
4

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1. Parasternal window -Long Axis View
1)LV inflow and outflow ;
Parasternal longaxis view allows visualization of Rt Ventricle ,
Ventricular Septum, Aorta, Lt ventricle, Posterior Wall,
Coronary sinus, Lt Atrium.

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1) LV inflow and outflow
Section Image Section Anatomy

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2) Tricuspid Inflow
1. Parasternal window -Long Axis View

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2) Tricuspid Inflow
Section Image Section Anatomy
RA
RV

17. 17
3) RV Outflow & Pulmonary valve
1. Parasternal window -Long Axis View

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3) RV Outflow & Pulmonary valve
Section Image Section Anatomy

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1. Parasternal window -Short Axis View
1) Aortic Valve Level

20. 20
1) Aortic Valve Level
Section Image Section Anatomy

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2) Mitral Valve Level
1. Parasternal window -Short Axis View

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2) Mitral Valve Level
Section AnatomySection Image

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1. Parasternal window -Short Axis View
3) Mid Papillary Muscle Level

24. 24
3) Mid Papillary Muscle Level
Section Image Section Anatomy

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2. Apical window
1) Four Chamber View ;
The 4chamber view displays all 4cardiac chambers, ventricular and
atrial septa, and crux for the heart.

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1) Four Chamber View
Section Image Section Anatomy

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2) Five Chamber View ;
By angulating the transducer in clockwise rotation, the 5chamber view
allows visualization of the LVOT and Aortic valve.
2. Apical window

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2. Apical window
3) Two Chamber View ;
Further rotation of the transducer clockwise produces the 2chamber
view, which is useful in visualizing the entire posterior and inferior
wall and in analyzing anterior wall motion.

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3. Subcostal window
1) Five Chamber View

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3. Subcostal window
2) Short Axis Atrial Septum

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4. Suprasternal window
1)Aortic Arch View ;
This transducer position allows visualization of the ascending
aorta, aortic arch, origin of the brachiocephalic vessels, and
descending thoracic aorta, Rt pulmonary artery.

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•Points on the B-mode line is moving along to Beam Line
Points on the Beam Line = Echogenicity from Heart Structure
Wave according to Time
M -mode
What is The M-mode ?
•One Dimension Echocardiology
•Transducer : One crystal
Transmitter for 1s
Receiver for 999s
•Recording the Echo from the Moving Heart on the Strip chart
according to Time
Repeat
1000/1sec

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M -mode
Clinical Applications of M-mode Calculation
•Measurement Position : Long Axis View, Short Axis View
•Size Measurement : Diameter -LV/LA/Ao/MV/AV B
•Depth / time
•RV & LV heart rate
•EF : Ejection Function
•Anatomy & Function Evaluation
•Wall Motion related to Time Evaluation
: Movement of MV, AV, Septum
•Size & Depth Evaluation
M-mode Calculation

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M -mode cursor : 3 level
1. Left Ventricular Level
2. Mitral Valve Level
3. Aortic Valve Level
M -mode Techniques & Evaluation

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1. Left Ventricular Level
M-mode Image & Plane
RV
LV

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RV
LV
2
1
3
4
5
6
7
1. Chest Wall 2. Anterior right ventricular wall
3.Right ventricle 4. Intraventricular septum
5. Left ventricle 6. Posterior Left ventricular wall
7. Pericardium

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Chest wall
Anterior right ventricular wall
Right ventricle
Intraventricular septum
Left ventricle
Posterior Left ventricular wall
Pericardium
ECG
Left Ventricular
Dimensions
Ventricular Septum
ST(D)
LVD(D)
MAX
LVD(S)
MIN Chordae tendineae
Endocardium
LV posterior free wall
PWT(D)
Epicardium

38. 38
4. LVIDs : Left ventricular end systolic dimension
Adult Normal Value
1. IVSDd : Intraventricular septal thickness
2. PWDd : Posterior wall thickness
3. LVIDd : Left ventricular end diastolic dimension
1
2
34
1. IVSDd : 07-11mm
2. PWDd : 07-11mm
3. LVIDd : 40-57mm
4. LVIDs : 20-40mm

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2. Mitral Valve Level
M-mode Image & Plane

40. 40
1. Anterior Right Ventricle Wall 2. Right Ventricle
3. Intraventricular Septum 4. Left Ventricular Outflow Tract/LV
5. Anterior Mitral Valve Leaflet 6. Posterior Mitral Valve Leaflet
7. Posterior Left Ventricular Wall 8. Pericardium
1
2
3
4
5
6
7
8
Mitral Valve Level

41. 41
Chest wall
Anterior right ventricular wall
Right ventricle
Intraventricular septum
Left ventricular outflow tract / LV
Posterior Left ventricular wall
Pericardium
Posterior mitral valve leaflet
Anterior mitral valve leaflet
Adult Normal Value
Left Ventricular Ejection Fraction : 56-78 %
Left Ventricular fraction Shortening : 21-40 %

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3. Aortic Valve Level
M-mode Image & Plane

43. 43
2
1
3
4
5
6
7
8
1. Anterior Wall of the Right Ventricle 2. Right Ventricle / RVOT
3. Anterior Wall of the Aortic Root 4. Aortic Root
5. Aortic Valve Leaflet 6. Posterior Wall of the Aortic root
7. Left Atrium 8. Posterior Wall of the Left Atrium

44. 44
Chest Wall
Anterior Wall of the Right Ventircle
Right Ventricle /RVOT
Anterior Wall of the Aortic Root
Aortic Valve leaflet
Aortic Root
Posterior Wall of the Aortic Root
Left Atrium
Posterior Wall of the Left Atrium
Anterior Wall of Aorta
Aortic Valve
Posterior Wall of Aorta
Posterior Wall of LA
Aortic Root and
Left Atrial
Dimension

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Adult Normal Value
1. Ao Diameter : 12 -37 mm
2. LA Diameter : 22 -40 mm
1
2
1. Ao : End Diastole Aortic Root Diameter
2. LA : End Systolic Left Atrium Diameter

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Color M-mode

47. 47
Color Doppler
What is The Color Doppler ?
•Based on PW Doppler principles
•Information of Direction, Velocity, Size of blood flow
•The colors do not appear when there is no blood movement.
•It displays intracavitary blood flow in Red & Blue color
Red color Blue color
Away flowForward flow
fast
slow
fast
slow

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Color Doppler
The Method of the Color Image acquisition
1. Multiple sampling site
along to ultrasound beam
2. Frequency shift measurement
at each sampling site
3. Conversion to a digital format
4. Display as color flow on 2D imaging

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Color Doppler
Clinical Applications of Color Doppler
•Valvular Disease Evaluation
-Regurgitation : Color Reversal
-Stenosis : Turbulent flow, Mosaic
-VSD/ASD :Flow mapping
-Shunt : Turbulent flow, Mosaic
Turbulence
Red Yellow
Blue Cyan
Slow
Fast
Fast
Slow
Forward
Reverse
Flow Direction
Flow velocity

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Normal color flow image
4-chamber
Color Doppler Techniques & Evaluation

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Normal color flow image
5-chamber

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Normal color flow image
long axis

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Abnormal color flow image
MR/AR color flow image

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Abnormal color flow image
AR color flow image

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Abnormal color flow image
AR flow

56. 56TR flow
Abnormal color flow image

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Abnormal color flow image
TR flow

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MR flow
Abnormal color flow image

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Spectral Doppler : PW & CW
What is The Spectral Doppler ?
•It is based Doppler Effect
•Information of blood-flow Velocity & Direction in heart and vessels
•It represents the change in blood flow velocity with respect to time
•There is a range of velocity in the blood flow
: The most fast in the center & Slower towards the wall
Stationary reflective object
Reflective object moving toward probe
Reflective object moving away from probe
Frequency
Frequency

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Spectral Doppler : PW & CW
Pulse Wave Doppler
The same crystal receives and emits the ultrasound
Sample Volume
probe
What is The Difference between CW & PW ?
PW
A Single Crystal

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Spectral Doppler : PW & CW
Pulse Wave Doppler
•The Method of the Image acquisition
-A Single Crystal
-Similar to image acquisition in B-mode :
Ultrasound is emitted from a single crystal with a certain frequency
and received from the reflected red blood cells at any depth
-Intermittent Transmitting & Receiving Ultrasound
PRF(Pulse Repetition Frequency)
•Sample volume :
Detecting the moving red blood cells at any depth in applied.

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PW Doppler
Pulse Wave Doppler
Spectral Doppler : PW & CW

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Spectral Doppler : PW & CW
Continuous Wave Doppler
Separate crystal exists for receiving and emitting ultrasound
probe
Receiving Crystal
Emitting Crystal

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Spectral Doppler : PW & CW
Continuous Wave Doppler
•The Method of the Image acquisition
-Two separate crystals :
One : continuously emitting ultrasound at a certain frequency
The other : continuously receiving the reflected ultrasound.
•All the red blood cells’ velocity Recording
-Not applying the sample volume theory
-Measuring velocity at a certain depth, all the red blood cells’
velocity in the ultrasound path is recorded.

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Spectral Doppler : PW & CW
CW Doppler
Continuous Wave Doppler

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Spectral Doppler : PW & CW
Comparison of CW & PWCW
Point of
Comparison
PW
Non-availableDepth information Available
HIGH Accuracy LOW
Infinity
Range of
velocity detection
Limited
Simple
Complexity
in operation
Complex

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Calculation of Spectral Doppler
Spectral Doppler : PW & CW
•LVOT velocity & TVI
•Volume measurements
•Diastolic function/filing
•Mitral inflow velocity
•Pulmonary
& Hepatic vein velocity
•Location of flow disturbance
•Mitral annulus velocity (DTI)
Continuous WavePulse Wave
•Peak-flow velocity & TVI
•Valvular Pressure Gradient
•Pressure Half Time
•Dynamic LVOT Gradient
•Pulmonary Pressure

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•Flow Dynamic Evaluation : Direction & Velocity &Pressure
-Flow velocity integral
-Pressure Gradient : LV&LA
-Pressure Half Time
-Acceleration
•Valvular Disease Evaluation
-Regurgitation : MR/TR/AR
-Stenosis :MS/TS/AS
-Valve area & V1/V2 ratio
•Shunt
•Evaluation of the Ventricle Systolic & Diastolic function
Clinical Applications of Spectral Doppler
Spectral Doppler : PW & CW

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Mitral Valve Doppler sampling
Normal Doppler Spectrum
Spectral Doppler Techniques & Evaluation

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Normal Doppler Spectrum
Mitral valve spectrum
pw cw

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Ao Valve Doppler sampling
Normal Doppler Spectrum

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Aortic valve PW spectrum
Normal Doppler Spectrum
pw cw

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Abnormal Doppler Spectrum
MR color/CW flow image

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Abnormal Doppler Spectrum
AR color/cw flow image

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Abnormal Doppler Spectrum
TR color/cw flow image

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MS PW spectrumMS M-mode
Abnormal Doppler Spectrum

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Cardiacmeasurement

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Cardiac Anatomy

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Doppler flow patterns
B-Mode
Normal(PW)
Mitral valve

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Mitral valve
Abnormal
Relaxation
(PW)
RestrictiveP
hysiology(P
W)

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MV
Regurgitation(CW)
Mitral valve

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B-Mode
Normal(PW)
Tricuspid valve

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TV
Regurgitation(CW)
Tricuspid valve

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B-Mode Normal(PW)
Aortic valve

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AoV
Regurgitation(CW)
Aortic valve

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B-Mode Normal(PW)
Pulmonary valve

88. 88
Pulmonary valve
PV
Regurgitation(PW)

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Pulmonary vein
B-Mode Normal(PW)

90. 90
Doppler measurement
Mitral valve

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Mitral valve

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Mitral valve

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Aortic valve

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Pulmonary valve

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Pulmonary valve

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Pulmonary vein

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Normal value
•Mitral flow : 0.90 0.6 ~ 1.3
•Tricuspid flow : 0.50 0.3 ~ 0.7
•Pulmonary artery : 0.75 0.6 ~ 0.9
•LVOT : 0.90 0.7 ~ 1.1
•Aorta : 1.35 1.0 ~ 1.7
Mean(m/s)Range(m/s)
Reference : The echo manual책자p.21

98. 98
Normal & abnormal range
Mitral Inflow
Normal RelaxationRestrictive
E velocity
0.7~1.2 m/sec < 0.7m/sec > 1.2m/sec
A velocity
0.42~0.7m/sec > 0.7m/sec <0.42m/sec
E/A Ratio
1.0~2.2 < 1.0 > 2.2
Decel time
150~240msec > 240msec < 150msec

99. 99
Aortic systolic
LVOT velocity(V1) 0.7 -1.1 m/sec
Peak Ao velocity(V2) 1.0 -1.7 m/sec
Mitral Diastolic
E peak velocity 0.8 ±0.2 m/sec
A peak velocity 0.5 ±0.2 m/sec
E/A ratio < 1.5
Deceleration time 190 ±20 msec
IVRT 70 -90 msec
Normal value

100. 100
Normal value
Aortic TVI 18 -22
MV TVI 10 -13
Pulmonary systolic
RVOT velocity 0.6 -0.9 m/sec
Time to peak ( ACC time < 120 msec )

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Severe mitral stenosis
MVA < 1.0 cm²
MDPG > 12mmHg
PHT > 220 msec
RV pressure
Normal 18 -25
Mild 30 -40
Moderate 40 -70
Severe > 70

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PISA Method

103. 103
Shift the color-flow zero baseline downward to increase hemispheric PISA ;
the negative aliasing velocity is usually 20 to 40cm/sec.
PISA Method

104. 104
PISA Method
Doppler to obtain peak mitral regurgitation velocity and TVI

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Mitral valve PISA
ERO RV(cc)
Mild < 10 1-25
Moderate 10 -25 25 –40
Mod & severe 25 -35 40 -55
severe > 35 > 55

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Aortic valve PISA
ERO
Mild < 25
Moderate 25 -30
severe > 30

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Qp : Qs measurement

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Qp : Qs measurement

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Qp : Qs measurement

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Qp : Qs measurement

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M-mode measurement
Lt. ventricle

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Lt. Ventricle measurement point
diastolesystole

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Aortic valve

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AAW
PAW
PLA
ALA
AAL
PAL
Aortic valve measurement point
AAW : anterior aortic wall
PAW : posterior aortic wall
AAL : anterior aortic leaflet
PAL : posterior aortic leaflet
ALA : anterior left atrium
PLA : posterior left atrium

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Mitral valve

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Mitral valve measurement point
D
E
F
C
A
EPSS

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Normal value
Aorta
diameter 21.7 -33.1
valve opening 15 -26
Left artrium
dimension 27.3 -44.0
Right ventricular
dimension 9 -26
Left ventricular
dimension(D) 42.5 -54.0
(S) 24.2 -35.8

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Ejection fraction 68 ±8%
Ventricular septum
thickness (D) 8.1 -11.5
Posterior wall
thickness (D) 8.1 -11.5
Mitral annulus 30 -35
Aortic annulus 18 -22
Normal value

119. 119
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The End