Introduction to Echocardiography PDF

Introduction to Echocardiography Slides written by Dr Robert Humphreys (Lecturer) Edited and Delivered by Dr Alexander Lee (Medical Demonstrator) [email protected] 1 Learning outcomes. • Understand the basics of Echocardiography. • Understand the different cardiac windows used in echocardiogr...

Introduction to Echocardiography Slides written by Dr Robert Humphreys (Lecturer) Edited and Delivered by Dr Alexander Lee (Medical Demonstrator) [email protected] 1 Learning outcomes. • Understand the basics of Echocardiography. • Understand the different cardiac windows used in echocardiography and relate the images seen to the underlying cardiac anatomy and physiology. • Have a basic understanding of the use of Echocardiography in assessment in the context of the Cardiology Clinic. • Have a basic understanding of the role of Echocardiography in Point of Care Ultrasound. 2 Echocardiography (‘echo’) • ‘echo’ is the use of ultrasound to examine the heart. • It is widely accepted that echocardiography has been one of the most dramatic revolutions in the field of cardiology in the last 100 years. • Amongst the non-invasive diagnostic procedures, the impact of this technique has been as profound as the revolution that occurred when Einthoven introduced the electrocardiogram. 3 Echocardiography (‘echo’) conti… • After the initial development of the technique in the field of cardiology in the 1990s, echocardiography became part of the arsenal of other specialties, mainly in the settings of anaesthesia, resuscitation, and paediatric cardiology. http://www.revespcardiol.org/en/is-it-possible-to-train/articulo/90273719/ 4 • Echocardiography is the most used and comprehensive cardiovascular imaging modality and is normally considered the first exam of choice for evaluating cardiac structure and function in most clinical conditions. Echocardiography • Compared with other imaging techniques, echocardiography may be done quickly, with the least trouble and distress to the patient, and provides speedy clinically relevant data at comparatively low cost. • Echocardiography also provides meticulous facts on cardiac structure, containing the size and shape of cardiac chambers, as well as the function and morphology of cardiac valves concomitant with systolic and diastolic function and intra cardiac haemodynamics. https://www.sciencedirect.com/topics/medicine-and-dentistry/echocardiography 5 Many different types Main focus for BSc level Advanced types (for reference) • Trans-thoracic echocardiography (TTE) • Trans-oesophageal echocardiography • Stress echocardiography • Contrast echocardiography • 3D echocardiography …etc Nonetheless, they all involve constructing images by using ultrasound waves. Advantages and disadvantages of echocardiography The Science for reference only 1. Ultrasonic waves generated and passed down to the target area 2. Sounds travel at different speeds in different types of tissue 3. Sounds bounce off various layers and return as ‘echoes’ 20,000 Hz 4. The different ‘echoes’ are recorded by the computer which lights up a ‘pixel’ to construct an image hyperechoic (white on the screen) hypoechoic (gray on the screen) anechoic (black on the screen) Echogenicity • Echogenicity of the tissue refers to the ability to reflect or transmit ultrasound waves in the context of surrounding tissues Fluid Blood Soft Tissue Bone Air Logic V2. Curvilinear Phased Array Linear 10 11 12 Unlike the Logic V2 the Versana Active does not have a dedicated button for Power Doppler Imaging so we have added it in under U1 (User configurable key). Types of transducers / Probes. 14 Linear-Array Transducers • Images obtained with linear arrays always have a flat superficial surface and are designated on the image with the letter L followed by the transmit frequency. • For example, a transducer with the notation HFL38/13-6 indicates that it is a high-frequency broadband (13-6 MHz) linear transducer with a 38-mm footprint. • High-frequency sound does not penetrate deeply into tissues, so high-frequency probes are only useful for superficial structures. 15 Curved-Array Transducers • If the surface of a linear array is reformed into a curved convex shape, it is called a curved array, curvilinear array, or a convex array. • Curved arrays can be formed in different sizes and shapes. Probes with a short radius of curvature can be used for endoluminal scanning and probes with a larger radius of curvatures can be used for general abdomen and obstetrical scanning. • Images obtained with curved arrays always have a curved superficial surface and are designated on the image with the letter C followed by the transmit frequency. 16 Phased-Array Transducer • With the phased-array transducer, every element in the array participates in the formation of each transmitted pulse. • Because the sound beams are steered at varying angles from one side of the transducer to the other, a sector image format is produced. • The phased-array probe is smaller and therefore capable of scanning in areas where acoustic access is limited, such as between ribs. 17 US probe manipulation manoeuvers “PART” • Pressure • Alignment (movement) • Rotation • Tilting (fanning) 18 Probe and Image Orientation • The US image must be properly oriented to accurately identify the anatomic relations of the various structures on the monitor. • To facilitate this, all US probes have an orientation marker, which is usually represented by a groove or a ridge on one side of the transducer and corresponds to a green dot (or a logo) on the monitor. • By convention, the orientation marker on the transducer is directed cephalad when performing a longitudinal scan and directed toward the right side of the patient when performing a transverse scan. • This way the orientation marker on the left upper corner of the monitor always represents the cephalad end during a longitudinal scan or the right side of the patient during a transverse scan. • The top of the display monitor therefore represents superficial structures and the bottom of the monitor the deep structures. 19 20 http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/1 21 Imaging windows. • An imaging window refers to an anatomic position on the patient’s body where an ultrasound transducer is placed to visualize specific structures. • For Transthoracic Ecchocardiography (TTE) there are three standard imaging windows. • 1. Parasternal. • 2. Apical. • 3. Subcostal. 23 http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/14 25 http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/22 26 The M-mode (Motion Mode). • The m-mode is designed to document and analyze tissue motion. • Using the 2D image as a guide, a particular scan line is selected to correspond to the moving structure of interest. • The reflections from this scan line are then displayed in a graphic form, with motion on the vertical axis and time on the horizontal axis. • This mode is particularly important in studying cardiac valve and wall motion and in documenting foetal heart rate and activity. 27 http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/26 28 http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/18 29 http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/30 30 http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/34 31 http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/38 32 http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/42 33 34 35 Basic Echo in Resuscitation (POCUS). • In contrast to formal echocardiography in which multiple views and techniques provide a comprehensive structural and functional assessment of the heart, resulting in a quantitative report, basic echo in the resuscitation setting aims to answer focused clinical yes/no questions. http://emergencyultrasoundteaching.com/image_galleries/cardiac_images/index.php 36 Basic Echo in Resuscitation (POCUS). • What are we looking for? • In the shocked, dyspnoeic, or arrested patient it looks for (or rules out): • Pericardial effusion (with or without signs of tamponade) • An enlarged RV (with or without hypokinesis and paradoxical septal motion) • LV size, in conjunction with IVC (eg small LV suggests hypovolaemia) • LV systolic function (rough estimate only) http://emergencyultrasoundteaching.com/image_galleries/cardiac_images/index.php 37 http://www.echobasics.de/tte-en.html#1 38 Marfan Syndrome • Marfan syndrome is one of the more common disorders of connective tissue that can affect the Eyes, Skeleton, Lungs, Heart and Blood Vessels, and may be life-threatening. • The effects of Marfan syndrome varies between individuals, some people only being mildly affected. 39 Cardiovascular complications of Marfan’s Syndrome. Dilatation of ascending and sometimes descending aorta, incompetence of aortic and mitral valves, aneurysm and dissection of aorta. 40 Assessment of aortic dilatation children Older adults Echocardiogram Sinus of Valsalva (2) Normalised for body surface area 41 Optimal management of Marfan’s Syndrome. Regular clinical review • echocardiogram • additional imaging if required (TOE, MRI, CT) • b blockers/ACEI • Surgical referral if aortic root at Sinus of valsalva exceeds 5.5 cm or 5% growth per year (2 mm in adults) 42 Neonatal Echcocardiography for detection of duct dependent congenital heart disease in particular. http://criticalcare.imedpub.com/neonatal-cardiac-emergencies-evaluation-and-management.php?aid=8723 43 Transoesophageal echocardiogram. • If it's difficult to get a clear picture of a patient’s heart with a standard echocardiogram or if there is reason to see the heart and valves in more detail, a transesophageal echocardiogram can be performed. 44 https://www.youtube.com/watch?v=9Us9mXXILSk 45 https://www.youtube.com/watch?v=hqZ_Zx59Uvo 46 https://st-andrews.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=01f7c899-1fea-4d96-adc3-aaa3009a532e 47 https://www.vscan.rocks/product/vscanair http://vscanair-support.gehealthcare.com/support/solutions Summary. • Echocardiography is an important tool in the diagnosis and management of cardiovascular disease. • The detailed cardiac structural and functional information that echocardiography provides, coupled with its portability and lack of ionizing radiation, has established this imaging modality as a critical tool in the care of patients with known or suspected cardiovascular disease. 57 Learning outcomes. • Understand the basics of echocardiography. • Understand the different cardiac windows used in echocardiography and relate the images seen to the underlying cardiac anatomy and physiology. • Have a basic understanding of the use of Echocardiography in assessment in the context of the Cardiology Clinic. • Have a basic understanding of the role of Echocardiography in Point of Care Ultrasound. 58