Echocardiogram Basics

echocrdiogram basics for graduate and postgraduate cardiac nurses.

1. BY
PRASANTH.K

2. Description
It is a type of ultrasound test that uses high-
pitched sound waves to produce an image of the
heart.
The sound waves are sent through a device called a
transducer 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.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

3. COMPONENETS
1.Pulse generator -applies high amplitude voltage
to energize the crystals
2.Transducer -converts electrical energy to
mechanical (ultrasound) energy and vice versa
3.Receiver-detects and amplifies weak signals
4.Display-displays ultrasound signals in a variety of
modes
5.Memory-stores video display
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

4. INDICATION
Information on valvularstructure and motion.
Cardiac chamber size and contents
Ventricular muscle , septalmotion and thickness
Ejection fraction
Pericardial sac
Ascending aorta
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

5. Cont….
Symptoms potentially due to suspected cardiac etiology.
Assessment of known or suspected adult congenital heart
disease.
Evaluation of suspected complication of myocardial
ischemia/infarction.
Evaluation of valvularor structural heart disease.
Initial evaluation of prosthetic valve for establishment of
baseline after placement.PRASANTH.K, CARDIOTHORACIC NURSING,
MSc, NARAYANA HRUDAYALAYA, BANGLORE

6. CONT..
Initial evaluation of suspected infective endocarditiswith
positive blood cultures or a new murmur.
Evaluation of cardiac mass (suspected tumor or thrombus).
Evaluation of pericardial conditions: i.e. pericardial
effusion, constrictive pericarditis.
Initial evaluation of known or suspected cardiomyopathy.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

7. PROCEDURE
A standard echocardiogram is also known as a
transthoracicechocardiogram (TTE), or cardiac
ultrasound.
The subject is asked to lie in the semi recumbent
position on his or her left side with the head elevated.
The left arm is tucked under the head and the right
arm lies along the right side of the body
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

8. Standard positions on the chest wall are used for
placement of the transducer called “echo windows”
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

9. ParasternalLong-Axis View
(PLAX)
Transducer position: left
sternaledge; 2
nd
–4
th
intercostalspace
Marker dot direction:
points towards right
shoulder
Most echo studies begin
with this view
It sets the stage for
subsequent echo views
Many structures seen from
this view
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

10. ParasternalShort Axis View
(PSAX)
Transducer position: left
sternaledge; 2
nd
–4
th
intercostalspace
Marker dot direction: points
towards left shoulder(90
0
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
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

11. Papillary Muscle (PM)level
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
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

12. 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
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

13. Apical 2-Chamber View (AP2CH)
Transducer position: apex
of the heart
Marker dot direction:
points towards left side of
neck (45
0
anticlockwise
from AP4CH view)
Good for assessment of
LV anterior wall
LV inferior wall
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

14. 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
Interatrialseptum, pericardial
effusion, descabdominal aorta
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

15. SuprasternalView
Transducer position:
suprasternalnotch
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
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

16. TYPES
Transthoracicechocardiogram
Standard echocardiogram.
It is a painless test similar to X-ray, but without the
radiation.
A hand-held device called a transducer is placed on the
chest and transmits high frequency sound waves
(ultrasound).
These sound waves bounce off the heart
structures, producing images and sounds to detect heart
damage and disease.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

17. CONT..
Transesophagealechocardiogram (TEE)
This test requires that the transducer be inserted down the
throat into the esophagus (the swallowing tube that
connects the mouth to the stomach).
The esophagus is located close to the heart, clear images
of the heart structures can be obtained without the
interference of the lungs and chest.
TEE provides superior image quality, particularly for
posterior cardiac structures which are nearer to the
esophagus and less well visualized on transthoracic
echocardiography
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

18. PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

19. NPO for six hours before the test
Dentures will be removed.
An intravenous line (IV) will be inserted into a vein ,so
that medications can be delivered during the test.
The electrodes are attached to an electrocardiograph
monitor that charts heart's electrical activity during the
test.
A blood pressure cuff will be placed on to monitor blood
pressure during the test.
A pulse oximeter, will be placed finger to monitor the
oxygen level of blood during the test.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

20. CONT..
A mild sedative will be given through IV.
A dental suction tip will be placed into mouth to remove
any secretions. A thin, lubricated endoscope (viewing
instrument) will be inserted into mouth, down throat, and
into esophagus.
Swallow at certain times to help pass the endoscope.
Once the endoscope is positioned, pictures of the heart are
obtained at various angles.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

21. CONTRAINDICATIONS
Unrepaired tracheoesophagealfistula
History prior esophageal surgery
Esophageal obstruction or stricture
Esophageal varicesor diverticulum
Perforated hollow viscus
Gastric or esophageal bleeding
Poor airway control
Vascular ring
Severe respiratory depression
Oropharyngealpathology
Uncooperative, unsedatedpatient
Severe coagulopathy
Cervical spine injury
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

22. COMPLICATIONS
Respiratory compromise
Laryngospasm
Hypoxia.
Bronchospasm.
Cardiovascular complications:
Tachyarrhythmias: -Ventricular tachycardia.
Supraventriculartachycardia.
Bradyarrhythmias: Third degree atrioventricularblock.
Transient hypotension or hypertension.
Angina pectoris.
Others:
Minor pharyngeal bleeding.
Nausea and vomiting.
Bacteremia
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

23. STRESS ECHOCARDIOGRAM
It is performed while the person exercises on a treadmill
or stationary bicycle.
To visualize the motion of the heart's walls and pumping
action when the heart is stressed. It may reveal a lack of
blood flow that isn't always apparent on other heart tests.
The echocardiogram is performed just prior and just after
the exercise.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

24. PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

25. NPO for four hours before the test.
Do not drink or eat caffeine products
(cola, chocolate, coffee, tea) for 24 hours before the test.
Do not take any over-the-counter medications that contain
caffeine for 24 hours before the test.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

26. CONT
Do not take the following heart medications for 24 hours
before the test unless doctor tells .
Beta-blockers (for
example, Tenormin, Lopressor, Toprol, or Inderal)
Isosorbidedinitrate(for example, Isordil, Sorbitrate)
Isosorbidemononitrate(for
example, Ismo, Indur, Monoket)
Nitroglycerin (for
example, Deponit, Nitrostat, Nitropatches)
Do not discontinue any medication without talking with
doctor.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

27. Dobutaminestress echocardiogram
A form of stress echocardiogram.
Instead of exercising to stress the heart, the stress is
obtained by giving a drug that stimulates the heart and
makes it "think" it is exercising.
The test is used to evaluate heart and valve function when
unable to exercise on a treadmill or stationary bike.
It is also used to determine how well heart tolerates
activity and likelihood of having coronary artery
disease, as well as evaluating the effectiveness of cardiac
treatment plan.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

28. Most dobutaminestress protocols start at an infusion
rate of 5microgram/kg/mtand increase to a peak dose
of 40 or 50 ug/ kg / min
To further increase heart rate, a bolus injection of
0.25—1 .0 mg atropine is added
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

29. PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

30. PREPARATION
Wear comfortable clothing.
Do not eat for a minimum of 4 hours before the test.
Drinking water is allowed before the test.
If diabetic, juice is allowed in the morning with insulin
(1/2 dose). If on pills ,do not take medication until after
the test is complete.
Do not drink caffiene(coffee or tea) the day of the test.
Stop taking all medications including beta
blockers, calcium channel blockers, nitrates and digoxin
for 24 hours prior to test
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

31. ECG electrodes will be placed to monitor
electrocardiogram
Blood pressure and ECG will be monitored throughout
the test.
Lie on left side on an exam table.
An intravenous line (IV) will be inserted and dobutamine
is administered . While the infusion of dobutamineis
going on continousecho images will be taken. The
medication will cause heart to react as if exercising.
The dobutaminemay give a warm, flushing feeling and
some patients experience a mild headache.
Report if there is chest pain, arm or jaw pain ,short of
breath, dizzy or feel lightheaded.
The IV line will be removed once all of the medication
has entered bloodstream.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

32. Intravascular ultrasound:
A form of echocardiography performed during cardiac
catheterization.
During this procedure, the transducer is threaded into the
heart blood vessels via a femoral catheter
Used to provide detailed information about the
atherosclerosis (blockage) inside the blood vessels.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

33. The Modalities of Echo
The following modalities of echo are used clinically:
1.Conventional echo
 Two-Dimensional echo (2-D echo)
 Motion-mode echo (M-mode echo)
2.Doppler Echo
 Continuous wave (CW) Doppler
 Pulsed wave (PW) Doppler
 Colour flow(CF) Doppler
All modalities follow the same principle of ultrasound
Differ in how reflected sound waves are collected and
analysed
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

34. Two-Dimensional Echo
(2-D echo)
This technique is used to "see"
the actual structures and motion
of the heart structures at work.
Ultrasound is transmitted along
several scan lines(90-120), over
a wide arc(about 90
0
) 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.
PRASANTH.K, CARDIOTHORACIC NURSING,
MSc, NARAYANA HRUDAYALAYA, BANGLORE

35. M-Mode echocardiography
An M-mode echocardiogram is
not a "picture" of the heart, but
rather a diagram that shows
how the positions of its
structures change during the
course of the cardiac cycle.
M-mode recordings permit
measurement of cardiac
dimensions and motion
patterns.
Also facilitate analysis of time
relationships with other
physiological variables such as
ECG, and heart sounds.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

36. (Time-motion mode)
M-Mode gives an ice-pick view of the heart.
The vertical axis gives the distance of each point from the
transducer while horizontal axis gives the time period.
M-Mode gives high resolution in the time axis so that it is
easy to time various events in the cardiac cycle, especially
if a syncronizedECG tracing is displayed along with it.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

37. It is used for taking measurements of the left ventricle in
systole and diastole to calculate the ejection fraction.
The thickness of the interventricularseptum (IVS)and left
ventricular posterior wall (LVPW) are measured at this level.
Asymmetric septalhypertrophy can be seen in hypertrophic
cardiomyopathy.
Septum can be thinned out in anterior wall mycoardial
infarction, while the posterior wall will be thinned in
inferoposteriorinfarction.
Normally the septum moves with the left ventricle, meaning
that it moves posteriorlyin systole. Paradoxical anterior
movement of septum in systole can be seen in atrialseptal
defect and other conditions of right ventricular volume
overload.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

38. Doppler echocardiography
Doppler echocardiography is a
method for detecting the direction
and velocity of moving blood
within the heart.
Pulsed Wave(PW) useful for low
velocity flow e.g. MV flow
Continuous Wave(CW) useful
for high velocity flow e.gaortic
stenosis
ColorFlow(CF) Different colors
are used to designate the direction
of blood flow. redis flow
toward, and blue is flow away
from the transducer with turbulent
flow shown as a mosaic pattern.
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

39. PERICARDIAL EFFUSION
PRASANTH.K, CARDIOTHORACIC NURSING,
MSc, NARAYANA HRUDAYALAYA, BANGLORE

40. PLEURAL EFFUSION
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

41. LEFT VENTRICULAR CLOT
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

42. MITRAL REGURGITATION
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

43. AORTIC REGURGITATION
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

44. EJECTION FRACTION
The volume of blood within a ventricle immediately
before a contraction is known as the end-diastolic
volume.
The volume of blood left in a ventricle at the end of
contraction is end-systolic volume.
The difference between end-diastolic volume (EDV) and
end-systolic volumes (ESV) is the stroke volume, the
volume of blood ejected with each beat.
Ejection fraction (E
f) is the fraction of the end-diastolic
volume that is ejected with each beat; that is, it is stroke
volume (SV) divided by end-diastolic volume (EDV)
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

45. CONT..
In a healthy 70-kg (154-lb) man, the SV is approximately
70 ml and the left ventricular EDV is 120 ml, giving an
ejection fraction of 70/120, or 0.58 (58%).
Healthy individuals typically have ejection fractions
between 50% and 65%
PRASANTH.K, CARDIOTHORACIC NURSING,
MSc, NARAYANA HRUDAYALAYA, BANGLORE

46. Ejection fraction is commonly measured by
echocardiography, in which the volumes of the heart's
chambers are measured during the cardiac cycle
It is calculated as a ratio of Dimension between the ventricles
in Systole and Diastole.
For example, a ventricle in greatest dimension could measure
6cm while in least dimension 4cm. Measured and easily
reproduced beat to beat for ten or more cycles, this ratio may
represent a physiologically normal EF of 60%. Mathematical
expression of this ratio can then be interpreted as the greater
half as Cardiac Output and the lesser half as Cardiac input
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE

47. THANK YOU
PRASANTH.K, CARDIOTHORACIC
NURSING, MSc, NARAYANA
HRUDAYALAYA, BANGLORE