Basic

Echocardiography

Selwyn Wong
Middlemore Hospital

   
 Echocardiography Basics
Ultrasound waves sent from chest wall

   
 Echocardiography Basics
Two-dimensional imaging

   
 Echocardiography Basics

   
 Echocardiography Basics

   
 Echocardiography Basics

   
 Echocardiography Basics
One-dimensional imaging (M-mode)

   
 Echocardiography Basics
One-dimensional imaging (M-mode)

   
 Echocardiography Basics
Doppler - Spectral
Pulse Continuous

  Bernoulli equation
  ∆P = 4V2
 Echocardiography Basics
Doppler - Colour

   
 Echocardiography Basics
Tissue velocity imaging

   
 Echocardiography Basics
Tissue velocity imaging

   
 Left ventricle - size

Normal
End-diastole
3.5-5.7cm
End-systole
2.1-4.0cm

   
 Left ventricle - size

Normal
End-diastole
3.5-5.7cm
End-systole
2.1-4.0cm

   
 Left ventricle - wall thickness

IVS and PW
0.6 -1.1cm

   
 Left ventricle - systolic function
Fractional Shortening (FS)

 
FS = EDD-ESD
 
/ EDD
 Left ventricle - systolic function
Fractional Shortening (FS)

 
FS = EDD-ESD
 
/ EDD
 Left ventricle - systolic function

   
 Left ventricle - systolic function

Ejection fraction (%)

Normal >55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe <20
   
 Part One
A 67-year-old woman with congestive cardiac failure remains
breathless on moderate exertion despite treatment with 40 mg
frusemide and 20 mg enalapril daily. On examination she has a pulse
rate of 80/minute, blood pressure of 125/70 mmHg and a jugular
venous pressure (JVP) of +1 cm. She has a soft systolic murmur with
no added sounds, her chest is clear and she has no oedema. An ECG
shows sinus rhythm. A chest X-ray shows cardiomegaly with a
cardiothoracic ratio of 15.5/28 but no pulmonary congestion.
Echocardiography demonstrates systolic dysfunction with fractional
shortening of 18% and mild mitral regurgitation. Her serum creatinine
level is normal.

Which of the following is the most appropriate next step in treatment?

A. Increase the frusemide dose.
B. Add digoxin.
C. Add an aldosterone antagonist.
D. Add an angiotensin II receptor antagonist.
E. Add a beta blocker.
   
 Left ventricle - diastolic function

Mitral inflow Pulmonary Mitral TVI

 
veins
 
 LV diastolic function - mitral inflow

E/A > 1 E/A < 1 E/A >>1

   
 LV diastolic function - mitral TVI

E/A > 1 E/A < 1 E/A >>1

   
 Left ventricle - RWMAs

   
 Left ventricle - RWMAs

   
 Left ventricle - RWMAs

   
 Left ventricle - thrombus

   
 Left atrium - size

Diameter
Normal 2.0-4.0cm
Mild 4.0-5.0cm
Moderate 5.0-6.0cm
Severe >6.0cm

   
 Left atrium - size

Area
Normal <20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe >40cm2

   
 Left atrium - thrombus

   
 Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
   
 Valve regurgitation - quantification

Colour - jet size/width

PISA
Spectral doppler

Consequences

   
 AR - LV Response

• Chronic AR - decompensated LV
• LVEF<55%, LVESD>55mm, LVESV 60ml/m2

   
 Part One
A patient with aortic regurgitation has the following haemodynamic
measurements:
cardiac output (CO) 7.5 L/minute
heart rate (HR) 75/minute
left ventricular end-diastolic volume (LVEDV) 200 mL
left ventricular end-systolic volume (LVESV) 50 mL
The regurgitant fraction is defined as the ratio of the regurgitant volume
to the total volume flowing through the valve with each beat.

The regurgitant fraction in this patient is:

A. 25%.
B. 33%.
C. 50%.
D. 67%.
E. 75%.

   
 Part One
A 45-year-old asymptomatic man returns for follow-up. He
was diagnosed 10 years ago with aortic regurgitation due
to a congenital bicuspid aortic valve. He has never had
endocarditis.
Which one of the following echocardiographic profiles most
strongly indicates the need for aortic valve replacement?
LVEDD (mm)[35-55] FS [0.30-0.40] LA size (mm) [<40]
A. 70 0.30 60
B. 75 0.40 40
C. 70 0.25 45
D. 65 0.45 50
E. 75 0.35 55

Key: LVEDD Left ventricular end-diastolic diameter

LVESD Left ventricular end-systolic diameter
FS Fractional shortening = (LVEDD - LVESD) / LVEDD
LA Left atrial
   
 MR- Quantification of LV contractility

LV systolic function - most important parameter

•Ejection fraction, fractional shortening, velocity of

circumferential fibre shortening - load dependent

•MR allows supranormal values of EF etc.

•Early systolic dysfunction if;

•EF < 60% (severe MR)

•ES diameter < 45mm (26mm/m2)

   
 Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild >2.0 <10-12 NL
Moderate 1.1-2.0 ~10-17 NL
Severe <1.0 >18 ↓
Very Severe <0.8 >20-25 ↓↓

   
 Part One
A 35-year-old woman has increasing breathlessness on exertion. Her
cardiac silhouette is slightly enlarged on a chest X-ray and an ECG
demonstrates sinus rhythm.
The continuous wave Doppler flow signal through the mitral inflow tract
(shown above) is most consistent with which one of the following?
A. Severe pulmonary hypertension (cor pulmonale).
B. Aortic stenosis.
C. Mitral regurgitation.
D. Mitral stenosis.
E. Aortic regurgitation.

   
 Part One
A 28-year-old woman, who emigrated from Cambodia 10 years ago,
presents to the emergency department with a three-week history of
increasing shortness of breath, orthopnoea, nocturnal dyspnoea and
ankle oedema. She is 25 weeks pregnant and has no significant past
medical history.
The presence of pulmonary oedema is confirmed clinically and
radiologically. She responds well to intravenous frusemide but remains
tachypnoeic with a heart rate of 120/minute in sinus rhythm. Her blood
pressure is 125/85 mmHg.
Echocardiography demonstrates mitral stenosis with an estimated valve
area of 1.3 cm2 and a left atrial diameter of 50 mm [<40 mm]. There are
no other abnormalities.
What is the most appropriate next step in management?
A. Balloon valvotomy.
B. Surgical valvotomy.
C. Digoxin therapy.
D. Beta-blocker therapy.
E.  Angiotensin converting enzyme (ACE)
  inhibitor therapy.
 Part One
A 55-year-old man presents with acute pulmonary oedema. Five years
earlier, he has undergone a mitral valve replacement with a bileaflet tilting
disk valve (St. Jude) for mixed mitral valve disease. He has been well
with normal exercise tolerance prior to the day of admission.
Examination on admission reveals tachypnoea, sinus tachycardia of
110/minute, blood pressure of 105/60 mmHg, elevated jugular venous
pressure (+ 5 cm) and bilateral crepitations throughout the lung fields. His
prothrombin time−international normalised ratio (PT-INR) is 1.9 [desired
therapeutic range 2.0-3.5]. Serum urea, creatinine and electrolytes are
normal. The cardiothoracic ratio on chest X-ray is normal but the
presence of pulmonary oedema is confirmed. Echocardiography reveals
that one of the prosthetic valve leaflets is not moving and there is an
increased flow rate in diastole across the valve orifice (2 metres/second).
What is the most appropriate course of action?
A. Administration of intravenous streptokinase.
B. Administration of intravenous heparin.
C. Administration of intravenous antibiotics.
D. Addition of an antiplatelet agent.
E.  Immediate mitral valve replacement.
  .
 Aortic stenosis - quantification

   
 Aortic stenosis - quantification
Mean gradient Peak Ao AVA
(mmHg) velocity (cm2)
Normal 1.0-2.0 >2.5
Mild <20 2.5-2.9 >1.7
Moderate 20-40 3.0-4.0 1.0-1.7
Severe >40 >4.0 <1.0

   
 Right ventricle - size & function

   
 Estimation of Pulmonary Pressure
PA systolic pressure
• Tricuspid regurgitation jet velocity

   
 Estimation of Pulmonary Pressure
RA pressure

• IVC size

   
 Part One
The severity of pulmonary hypertension can be determined using
continuous wave Doppler measurements of the velocity of tricuspid
regurgitation. This method uses the Bernoulli equation which states that
P = 4v2 (where P = instantaneous pressure gradient and v = velocity
across the valve). There is tricuspid regurgitation with a peak velocity of
4 metres/second and a mean velocity of 3.5 metres/second.
Assuming right atrial pressure is 5 mmHg, the best estimate of the peak
right ventricular systolic pressure (± 2 mmHg) is:

A. 50 mmHg.
B. 55 mmHg.
C. 60 mmHg.
D. 65 mmHg.
E. 70 mmHg.

   
 Cardiac Tamponade

   
 Cardiac Tamponade

   
 Cardiac Tamponade

   
 Part One
A 65-year-old woman presents with a one-week history of progressive
dyspnoea. On admission, there are signs of shock, a systolic murmur
and an elevated jugular venous pressure. The ECG shows sinus
tachycardia but no other abnormality. An antero-posterior chest X-ray
shows cardiomegaly. The serum troponin I level is 0.5 mg/L [<0.1]. A
computed tomography (CT) scan is shown below.

What is the most likely diagnosis?

A. Pulmonary embolism.
B. Right ventricular infarction.
C. Pericardial tamponade.
D. Myocarditis.
E. Acute mitral regurgitation.

   
 Endocarditis

Positive echocardiogram for IE

Discrete, echogenic, oscillating intracardiac mass located at a site of
endocardial injury (e.g., on a valve or supporting structure, in pathway of
regurgitant jet, or site of implanted material), or Periannular abscess, or
  New dehiscence of  a prosthetic valve
 Cardiac Resynchronisation

   
 Cardiac Resynchronisation

•Severe heart failure

treatment to restore co-
ordination to LV contraction

•NYHA 3-4
•EF < 35%
•QRS duration > 120 msec

   
 Echocardiography

•Useful non-invasive tool

•Reports objective and subjective
•Limitations