2 d echo

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Cardiac imaging Part 2-Echocardiography:

Cardiac imaging Part 2-Echocardiography Dr Gayatri PGY3 General Medicine

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Echocardiography ‘heart of the clinical cardiology’ ‘fastest growing technique & is likely to be the stethoscope of future’- ACC Roadmap What is echo? Basic modalities & views Functions assessed Various diseased states except CHD

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Basic modalities Conventional 2 D & M mode imaging Doppler modalities including colour flow imaging Rely on ‘piezoelectric element’ located in the transducer These crystals vibrate by passage of EC & generate ultrasound waves which are transmitted by body Part of ultrasound waves are reflected back & are elecrtonically processed in the equipment producing characteristic images

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Infants High frequency transducer [4 to 7.5 mHz ] is used Less penetration & better resolution since the cardiac structures are closer to chest wall Adults Low frequency transducer Since they need deeper penetration but lesser resolution

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M mode Echo The earliest form of ECHO examination Limited information since it is single point study & does not provide information in lateral dimension 2 D echo Gives wide view of the heart Gives complete anatomical & functional information including EF Does not provide any hemodynamic function

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Standard imaging planes Parasternal long axis view [PLAX] Images of heart in a long axis Slices are from the base of the heart to apex Marker dot is to the right shoulder

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Short axis view- SAX view Aortic valve Great vessels Mitral valve Papillary muscles apex

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Apical views Four chamber Three chamber or long axis Two chamber Five chamber Subcostal view Best for pediatric examination Special situations Suprasternal , right parasternal & right supraclavicular

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Each transducer has index mark which is utilised for imaging the structures in particular format Eg , apical 4 chamber view If index mark is pointing towards the right sholder then LV will be on left side of the screen If its at 3 ‘o clock position then it will be on the right side of the screen

Apical views, 4 chamber & 2 chamber:

Apical views, 4 chamber & 2 chamber

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Doppler echocardiography Uses ultrasound reflecting off moving RBCs to measure the velocity of blood flow across valves, cardiac chambers & through great vessels Normal & abnormal patterns can be assesed Colour flow doppler imaging displays the blood velocities in real time superimposed upon 2 D echo image Different colours denote direction of flow Red towards Blue away from the transducer Green superimposed when there’s turbulent flow

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Pulsed-wave Doppler measures the blood flow velocity in a specific location on the 2D echocardiographic image. Continuous-wave Doppler echocardiography can measure high velocities of blood flow directed along the line of the Doppler beam,eg presence of valve stenosis valve regurgitation intracardiac shunts.

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Doppler records velocity of a blood flow at the particular area. It is used to determine intracardiac pressure gradients by a modified Bernoulli equation: Pressure change = 4 times (velocity) 2 Tissue Doppler echocardiography measures the velocity of myocardial motion.

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Colour flow mapping Automated 2D version of pulsed doppler wherein actual colour flow can be seen Normally colour flow are smooth In diseased states additional colours are added to the conventional colours k/a “mosaic pattern”

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Haemodynamic information 2D echo gives structural & functional information & doppler gives a haemodynamic information eg velocities & gradients Impt of determining RAP Idea of intravascular volume status & it helps in management strategy RAP is added to various right heart haemodynaic values to get correct no.

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RA pressure is mainly evaluated by IVC diameter & its collapsibility during spontaneous respiration Evaluated by subcostal view IVC collapsibility IVC max diameter-IVC min diameter ×100/IVC max diameter Normally, more than 50% collapsibility & mean RAP is abt 10 mmhg Dilated IVC with less than 50% collapse indicated RAP of 15mmg dilated IVC & hepatic veins with no significant collapse of IvC indicate RAP of 20mmhg Small IVC <1.2cm with spontaneous collapse may indiacte hypovlemia

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RV & PA pressures Identical in absence of RVOT obstruction Quantification is done by jet of TR RV/PA pressure= 4V2+RAP Underestimated usually & its +/- 10mmhg

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Evaluation of cardiac function Systolic LV function LVEF = stroke volume÷end diastolic volume Factors affecting EF Preload Afterload Contractility Heart rate Arrythmias Delineation Grossly distorted left ventricle Abnormal septal motion

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According to American Society Of Echocardiography [ASE] Normal value>55% Mildly abnormal >45-54% Mod abnormal 30-40% Severly abnormal <30%

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Diastolic function Isolated diastolic dysfunction is also k/a heart failure with normal ejection fraction [HFNEF] Seen in HTN with or without DM CAD Cardiomyopathy Obesity Sleep apnea $

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The anterior leaflet of the mitral valve opens widely at the beginning of diastole (D), reaching a peak at the end of rapid left ventricular filling (E). During diastasis, the valve leaflet floats back towards a closed position (E) and it opens again with atrial systole (A). At the end of diastole and the initiation of systole, the mitral leaflets are closed (C). The posterior leaflet is a mirror image of the anterior leaflet except that its amplitude of motion is less.

Doppler mitral inflow velocity :

Doppler mitral inflow velocity Transmitral Doppler flow is acquired by placing a one to two mm pulsed wave sample volume at the level of the tips of the mitral leaflets in the apical four-chamber view Normal inflow pattern consists of early (E) and late (A) filling

Doppler criteria for classification of diastolic function:

Doppler criteria for classification of diastolic function

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Diagnosis of HFNEF Presence of HF clinically Normal EF Presence of diastolic dysfunction E/E’ >15:1 indicative of increased LV filling pressure Usually non dilated heart

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Pericardial disease Imaging modality of choice for the detection of pericardial effusion Visualized as black echolucent ovoid structure surrounding the heart Pericardial tamponade Echo findings include dilated IVC, right atrial collapse & right ventricular collapse Next Mx should be ECHO guided pericardiocentesis

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Intracardiac masses Solid masses appear as ECHO dense structures Eg LV thrombus, usually in the apical region associated with RWMA Appearnace of & mobility of the thrombus are predictive of embolic events Vegetations appear as mobile linear ECHO densities attatched to valve leaflets Atrial myxoma - appearance of of a well circumscribed mobile mass with attatchment to atrial septum

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Valvular heart disease Stenotic lesions Thickening/fibrosis/calcification depending upon the stage of the disease Doming of the cusps Reduced valve mobility Decreased valve orifice area Increased transvalvular gradients across the stenotic valve depending on the degree of the stenosis

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Mitral stenosis Diastolic doming of MV Fish mouth appearance Severity of MS MVOA by planimetry & pressure half time Mean gradient Calculation of PA pressure Calcification, submitral fusion LA enlargement* Size & site of LV clot

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Assessment of severity of mitral stenosis MVOA [cm2] Mean grad[ mmhg ] PASP[ mmhg ] Mild MS >1.5 to 2 < 5 < 30 Moderate MS 1 to 1.5 5 to 10 30 to 50 Severe MS < 1 to 0.5 10 to 20 >50 Critical MS <0.5 >20

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Aortic stenosis Valve thickening & doming All severe AS in adults are calcified Allows definition of valve anatomy, cause of AS,calcification & assessment of severity of AS Assessment of aortic root dilation & associated MV disease

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Pulmonary stenosis Parameters of severity Degree of obstruction Peak systolic doppler gradient [ mmhg ] RV systolic pressure [ mmhg ] trivial <25 <50 mild 25 to 49 50 to 74 moderate 50 to 79 75 to 100 severe >80 >100

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Valvular Regurgitation Diagnosed by Doppler echocardiography when there is abnormal retrograde flow across the valve. Color-flow imaging/mapping [CFM] used most frequently to detect valve regurgitation by visualization of a high-velocity turbulent jet in the chamber proximal to the regurgitant valve Size and extent of the color-flow jet into the receiving cardiac chamber provide a semiquantitative estimate of the severity of regurgitation.

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MR Dilated LA & LV Assess mitral apparatus for cause of MR MR is severe when MR jet area to LA jet area >50% Systolic flow velocity reversal in pulmonary vein Vena contracta >6mm

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Ischemic heart disease Role of ECHO in IHD Diagnosis Diagnosis if any asso . Cardiac defects Triage in chest pain units Assessment of complications such as LV thrombus, acute MR, VSD,LV aneurysm, myocardial rupture,RV infarction Assessment of coronary artery involved Post MI risk stratification/prognosis Assessment of myocardial viability

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Ischemic heart disease AMI Earliest abnormality is a perfusion defect f/b diastolic & systolic contraction abnormalities which is then f/b ECG changes & rise in cardiac enzymes 95% sensitive in AMI & hence life saving Specific diagnostic findings Decreased systolic thickening of affected myocardial seg Varying degree of RWMA

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RWMA is always assessed by scanning various imaging planes On this basis myocardium is divided into 17 seg 17 th seg being apical cap

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Stress Echocardiography It’s a reimaging during either exercise or pharmacologic stress. Primary indications To confirm the suspicion of ischemic heart disease Determine the extent of ischemia. Decrease in systolic contraction of an ischemic area (segment) of myocardium, termed a regional wall motion abnormality, occurs before symptoms or electrocardiographic changes

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Indicators of myocardial ischemia. New regional wall motion abnormalities Decline in ejection fraction Increase in end-systolic volume with stress Usually done with exercise protocols using either upright treadmill or bicycle exercise

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In patients who are not able to exercise, pharmacologic testing can be performed by infusion of dobutamine to increase myocardial oxygen demand. Dobutamine echocardiography Assesses myocardial viability in patients with poor systolic function and concomitant CAD When used for this purpose, dobutamine is administered at lower doses than standard pharmacologic stress doses.

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Infective endocarditis Role of ECHO for IE Identifying the underlying heart disease including intracardiac device Diagnosisof vegetations Size, mobility & location Detecting complications of vegetations Serial evaluation For prognosis eg adverse prognosis when >10mm, hypermobile vegetations, abscess, leaflet rupture, extension in other areas

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TEE for IE

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Transesophageal Echocardiography Diseases of the aorta, such as aortic dissection, can be readily diagnosed by TEE. Defining the source of embolism- atrial thrombi patent foramen ovale aortic plaques can be detected.

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TEE Indications Presence of vegetations for the diagnosis of infective endocarditis and its complications Used before cardioversion in patients with atrial fibrillation to rule out a thrombus in the left atrium or left atrial appendage.

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References API Textbook of Medicine-9 th edition Harrison’s 18 th edition Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. Echo made easy- 2 nd edition

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