Uncategorized

echocardiography for beginners techniques and approaches to cardiac ultrasonic evaluation you parasternal long axis view one starts an ultrasound exam of the heart by obtaining an image using the parasternal approach the scanning plane is located along the longitudinal axis of the heart one places the transducer perpendicular to the anterior thoracic wall in the left third or fourth intercostal space adjacent to the sternum the scanning plane should follow an imaginary line that connects the apex and the middle part of the right clavicle one can perform the examination in the supine position but it is better to turn the patient on his or her left side you in the upper part of the screen one will see the hearts structures that are situated more closely to the surface of the transducer when one looks farther down the screen one will see the image of the anterior right ventricular wall more deeply the interventricular septum under the interventricular septum the left ventricular cavity one can see the papillary muscles Corday and mitral valve leaflets at the bottom of the screen one sees the image of the posterior left ventricular wall the interventricular septum directly continues into the anterior aortic wall and the anterior mitral valve leaflet continues into the posterior a aortic wall in the root of the aorta one will see the motion of two aortic valve leaflets the upper leaflet is always the right coronary leaflet of the aortic valve the lower leaflet can be the left coronary or non coronary leaflet of the aortic valve depending on how the scanning plane has been angled in most cases one cannot clearly discern the motion of the aortic valve leaflets because they are very thin in systole the aortic valve leaflets are seen as two parallel short strips which are positioned adjacent to the aortic walls in diastole one will see the leaflets at the point where they close in the center of the aortic root one can see the aortic valve leaflets more clearly when they are thickened or in a very slim patient when there is a proper acoustic window most of the time one can easily see mitral valve leaflets during diastole the mitral valve opens twice when the patient is in sinus rhythm at the start of diastole the left ventricle relaxes and fills up with blood from the left atrium during this time the mitral valve leaflets separate and droop into the left ventricular cavity when the early diastolic period is finished and the left ventricle is filled with blood the mitral leaflets move in the direction of the left atrium at this moment they are partly closed this is called early diastolic closure of the mitral leaflets the second opening of the mitral leaflets in diastole is a result of late diastolic blood flow in the left ventricle after the cystal of the left atrium the amplitude of the second opening of the mitral valve leaflets is lower than the early diastolic open after the completion of the second opening one will see the start of the left ventricular systole and the mitral valve leaflets closed in a very short period of time after the mitral valve closure one will see the opening of the aortic valve leaflets normal mitral valve leaflets open like a door therefore the highest amplitude has the dots that are situated on the tips of the mitral valve leaflets in the case of mitral stenosis the anterior mitral valve leaflet is ballooning in diastole like the canopy of a parachute after one has evaluated the structure and motion of the mitral and aortic valve leaflets one may begin to assess the wall motion

normally the left ventricular wall must contract and thicken uniformly in all segments and the opposite walls must approach one another on the parasternal long axis view the shape of the left ventricle resembles an equilateral triangle the tip of this triangle is formed by the left ventricular apex and the base is a straight line which connects basal ends of the opposite walls during systole the walls of the triangle thickened uniformly the tip of this triangle approaches the base and the opposite dots on the walls of the triangle approach their axis at equal distances therefore the ventricular walls uniformly approach each other and uniformly thickened on the parasternal long axis view of the left ventricle one observes the contraction of the interventricular septum and the posterior left ventricular wall the parasternal long axis view does not show the apex in most patients therefore one cannot assess its shortening in this image one can see not only the ascending aorta but also the descending aorta behind the left atrium in cross-section in the atrioventricular groove one can often see the round formation with the smaller diameter than the diameter of the descending aorta this is the coronary sinus which collects venez blood from the myocardium and transfers it into the right atrium a small percentage of people can have dilated coronary sinus in such cases it could be erroneously interpreted as a descending aorta after a visual assessment of the heart in the parasternal long axis view one may measure the dimensions this is a very important part of air-cool card iographer the dimensions must be measured correctly and uniformly so that one can perform a follow-up of the disease’s progression in modern echocardiography m-mode is not the best method for taking dimensions echo machines have a sine loop function which allows the echocardiography to easily obtain a high-quality image at the end of diastole in this image one can measure all necessary dimensions the dimensions of both ventricles should be obtained on the line that is perpendicular to the interventricular septum and that goes between the tips of the mitral valve leaflets and the papillary muscles you the anterior right ventricular wall right ventricular cavity interventricular septum left ventricular cavity the posterior left ventricular wall after one has finished measuring the dimensions of the ventricles one measures the dimensions of the ascending aorta and of the left atrium in the case when a patient is going to have a or tick valve replacement one should also measure the dimension of the aorta at the level of the aortic valve this dimension helps the surgeon to choose the right size of the aortic prosthesis experienced cardiologists do not use the M mode for taking dimensions and calculating the left ventricular ejection fraction the measurements are made on a two dimensional image and the ejection fraction is assessed visually for example less than 30 percent thirty to forty percent forty to fifty-five percent and more than 55 percent at this stage one may start colorflow Doppler imaging one chooses the right size of the color Doppler sector and places it in a two-dimensional image so the sector captures the mitral and aortic valves and the upper part of the interventricular septum in the limits of this sector one can assess the type and velocity of blood flow if one sees only red and blue colors in the dopplers color sector this indicates that only

normal laminar blood flow is present and that regurgitant jets or high-velocity flows through the sanest valves are absent regurgitant debts or turbulent high-velocity blood flows will be represented by a green color or a bright mosaic of colors with post Doppler one can evaluate zones either under or above the valves in this case one should shift the sample volume to the zones of interest therefore in summary the parasternal long axis view is the main view and one must start cardiac ultrasonic evaluation here this view is also the starting point for obtaining other two-dimensional echocardiograms the parasternal long axis view gives one the possibility one to diagnose a or D’Cruz pathology dilation dissection atherosclerosis of the aorta two to diagnose a or Tek valve pathology anomalies kalsa gnosis vegetations thickening three to diagnose sub valvular left ventricular outflow tract obstruction membranous or muscular stenosis four to assess left ventricular systolic function 5 to determine the amplitude of motion and thickness of the interventricular septum and posterior left ventricular wall 6 to see membranous defects of the interventricular septum 7 to confirm mitral a or tech fibrous continuance this is important in the diagnosis of some congenital heart diseases 8 to diagnose structural changes and dysfunctions of the mitral valve and its supporting structures cord papillary muscles 9 to diagnose coronary sinus dilation this can be evidence of persistent left superior vena cava 10 to assess the left atrium and to diagnose masses inside it thrombus maxima membrane 11 to perform quantitative Doppler echocardiography of mitral or aortic insufficiency 12 to diagnose muscled effects of the interventricular septum with color Doppler imaging or pulsed Doppler recording and to measure in this case the systolic pressure gradient between ventricles this pressure gradient gives one the possibility to assess systolic pressure in the right ventricle and pulmonary artery parasternal long axis view of the right ventricular outflow tract now one will try to see the pulmonary valve together with the right ventricular outflow tract and pulmonary artery trunk after one has obtained a good image of the left ventricle from the parasternal long axis view one must rotate the transducer a bit counterclockwise and angle it at a sharp angle between the transducer and anterior thoracic wall it will appear as if one is trying to look under the left shoulder joint sometimes this maneuver is not easy it is helpful if the patient will hold his or her breath after exhaling the motion of the pulmonary valve leaflets is similar to the motion of the aortic valve leaflets during systole the leaflets get in close contact with the pulmonary artery walls and one cannot see them however during diastole the leaflets close and the backward blood flow from the pulmonary artery into the right ventricle terminates as opposed to a normal or tech valve one can often see a mild regurgitant flow in a normal pulmonary valve if one places the post wave sample volume at the level of the pulmonary artery valve or in the right ventricular outflow tract one will obtain the pulmonary artery Doppler flow velocity wow-wow-wow-wow doppler recordings of the pulmonary artery velocity can provide the assessment of the pulmonary artery pressure for this one measures the acceleration time the time between the onset of the flow

to the peak systolic flow when pulmonary artery pressure goes up the acceleration time becomes shorter as a norm it should exceed 100 milliseconds if this parameter becomes less than 75 milliseconds one can diagnose it as severe pulmonary hypertension this is an example of a patient with pulmonary hypertension you this image gives us the possibility one to assess the right ventricular outflow tract two to assess the motion and structure of the pulmonary artery valve leaflets three to see the proximal part of the pulmonary artery for to assess the pulmonary artery pressure five to assess the function of the pulmonary artery valve pulsed Doppler continuous wave Doppler and color flow imaging parasternal long access view of the right ventricular inflow tract after one has obtained at the parasternal long axis view of the left ventricle one can rotate the transducer a bit clockwise and angle it as if one is trying to look under the xiphoid process in this image one can see the position and motion of the tricuspid valve leaflets normal tricuspid valve leaflets open in the same manner as mitral valve leaflets double motion open closed open normal tricuspid valve leaflets should open like a door so the tips of the tricuspid valve leaflets have the biggest amplitude in the case of tricuspid stenosis the leaflets dome in a diastole like a parachute doming is one of the main 2-dimensional features of any stenotic valve in this image one can see the spot where the coronary sinus empties into the right atrium this is the diaphragmatic surface of the heart between the right ventricle and the right atrium parasternal short axis views of the left ventricle after one has obtained the parasternal long axis view of the left ventricle one can rotate the transducer clockwise until the scanning plane is perpendicular to the long axis of the heart after this step one can sweep the transducer so that one is trying to look under the suprasternal notch or one can sweep downwards in the direction of the apex in this way one can obtain many cross-sectional images of the left ventricle you if the transducer is perpendicular to the anterior thoracic wall and the scanning plane is perpendicular to the long axis of the left ventricle one will obtain the parasternal short axis view at the papillary muscles level you one can see papillary muscles as two round echogenic masses that are situated near the left ventricular wall different patients have different positions of papillary muscles one of the papillary muscles is posteromedial and the other anterolateral if one sweeps the transducer downwards in the direction of the apex one will obtain the short axis view at the level of the apex in this image one can see that the left ventricular cavity is round but the

right ventricular cavity resembles a triangle and has distinct trabecular T one should pay attention to the contractility of the left ventricle or all segments of the left ventricle contracting synchronously after one has obtained a short axis view at the papillary muscles level one can sweep the scanning plane a little towards the base of the heart as a result one will obtain a short axis view at the mitral valve level you when evaluating this image one can see one the motion of the mitral valve leaflets and the tricuspid valve leaflets in diastole they move in opposite directions and in systole they move towards each other to the contractility of different segments of the left ventricle normally all segments must contract and move to the center of the left ventricle at equal distance they must thicken at the same time 3 one can also assess the motion of interventricular septum as a norm it should occur during the left ventricular systole thus the interventricular septum moves towards the center of the left ventricle for one can assess the shape of the right ventricle it should have a triangular or Crescent like form and the right ventricular free wall and cystal should move in the same direction as the interventricular septum if one sweeps the transducer a little more towards the base of the heart one obtains a short axis view at the aortic valve level you in this image one can see aortic valve leaflets in the center of the root of the aorta in closed position the leaflets form the shape of the letter Y or the Mercedes logo the right coronary cusp is on the top and near the right ventricular outflow tract the non coronary cusps is at the bottom and to the left near the right atrium and the left coronary cusps is at the bottom and to the right near the left atrium in systole the aortic valve leaflets open and form the shape of a triangle this is another image where one can assess the right ventricular outflow tract that forms the arc interior from the aortic ring in this image one can also see the initial part of the pulmonary artery and pulmonary valve in this image one can easily see the structure and motion of the pulmonary leaflets and evaluate the flow with the DA wow wow wow wow this image is very important in evaluating the congenital anomalies of the aortic valve for example the bicuspid aortic valve which is the most frequent congenital anomaly of the heart in slim patience with proper acoustic windows one can sometimes see the left coronary artery if one sweeps the scanning plane a little more towards the base of the heart one will obtain an image at the level of the pulmonary artery bifurcation you this image is important in patients with congenital anomalies of the heart because it allows one to evaluate the anatomic features of the pulmonary artery the diameter of its branches you and to perform doppler flow recordings in the pulmonary artery the segmental approach to analyzing regional ventricular function short axis views four views are used for regional wall analysis the longitudinal and short axis examinations complement each other and give one the opportunity to look at essentially the same segments in more than one view in longitudinal views we

divide the left ventricle into basal middle and apical thirds the short axis at the mitral valve and papillary muscle levels are divided into six segments whereas the short axis at the apex has four segments on this scheme one can see the short axis at the mitral valve level in this image one can see six segments of the short axis at the mitral valve level anterior lateral posterior inferior inferior basal septal anterior basal septal you in this image one can see six segments of the short axis at the papillary muscles level anterior lateral posterior inferior inferior middle septal anterior middle septal in this image one can see four segments of the short axis at the apex level septal anterior lateral inferior we assess the contractility of all 16 segments with the use of long axis scans and short axis scans when we use the parasternal long axis view of the left ventricle we cannot see the apical third of the left ventricle in many patients thus we must assess the contractility of the apex with the use of a pickle – and for chamber views apical images you one should place the transducer in the area of the apex of the heart and the scanning plane must be directed in such a way that one obtains the image of all four chambers of the heart for optimal visualization the patient should be put on his or her left side and the transducers should be placed in the area of the apical impulse palpation one should aim the transducer in the direction of the right scapula traditionally one obtains an image where the heart is placed with its apex at the top of the screen left chambers are on the right of the screen and right chambers on the left when one uses the four chamber apical examination one can differentiate the right ventricle from the left ventricle by the following features one the insertion of the septal tricuspid valve leaflet is slightly apical the insertion of the anterior mitral valve leaflet to in the apical third of the right ventricle one can see the moderator bend three the right ventricle has a more pronounced trabecular structure downward from the left atrium one can see the cross-section of the descending aorta one can also see the pulmonary veins entering the left atrium by tilting the transducer downwards one can see the coronary sinus one should keep in mind that with the transducer in this position ultrasonic beams are parallel to the interventricular and interatrial septum x’ the interatrial septum is very thin especially in the region of the fossa ovalle by using the apical approach one gets the impression that the central part of the interatrial septum is absent in this case one should use the subcostal approach for optimal visualization of the interatrial septum in an apical for chamber examination the scanning plane crosses the inferior segment of the interventricular septum it is important to keep this aspect in mind when assessing the patient with

coronary heart disease in typical cases the inferior segment of the interventricular septum receives blood flow from the right coronary artery or the circumflex artery as opposed to other segments of the interventricular septum which receive blood from the left descending coronary artery during an apical for chamber examination one should evaluate whether the left ventricular walls contract uniformly one must also assess the structure and motion of the mitral and tricuspid valves this approach is ideal for Doppler recordings of blood flow through mitral and tricuspid valves because the Doppler ultrasonic beam is parallel to the direction of blood flow when one is performing a Doppler recording of blood flow through the mitral orifice one should place the sample volume at the tips of the mitral leaflets this Trane’s mitral Doppler waveform allows us to assess the left ventricular diastolic function Oh in the presence of mitral regurgitation one will register turbulent regurgitant flow in the system with pulsed Doppler sample volume one can map the severity of mitral regurgitation this is achieved by moving a sample volume across the area of interest if there is a mitral stenosis present one should use continuous wave Doppler for quantitative calculation this method will allow to measure the area of the mitral orifice and to determine the mean pressure gradient across the mitral valve you the assessment of the trike spit valve is essentially the same if one has revealed even minimal tricuspid regurgitation one should use continuous wave Doppler for measuring the systolic pressure gradient through the tricuspid valve this systolic pressure gradient exists between the right ventricle and the right atrium in the presence of tricuspid regurgitation the pressure gradients can be determined by using the peak velocity of the tricuspid regurge attend jet flow knowing the gradient across the tricuspid valve one must add the right atrial pressure to determine the right ventricular systolic pressure and pulmonary artery pressure after one has obtained an apical for chamber view one can tilt the transducer a bit towards the sternum in order to obtain a so-called five chamber view the left atrium the left ventricle the right ventricle the right atrium the aorta in addition to four chambers there is also a so-called fifth chamber the ascending aorta one can evaluate the mitral and aortic valves with the color Doppler on the right part of the screen one can find a color map that demonstrates which color will correspond to which direction of the blood flow the blood flow that moves in the direction away from the transducer will be marked in blue and the blood flow that moves in the direction of the transducer will be marked in red this image is ideal for a pulsed waved a player cording of blood flow across the aortic valve because the blood flow Direction is parallel to the Doppler ultrasonically Wow first one should place the post Doppler sample volume in the center of the aorta at the level of the aortic valve one will register the Doppler recording of systolic blood flow through the aortic valve and measure the velocity of

systolic blood flow if the aortic valve stenosis is present one will register the turbulent systolic flow with a pulsed Doppler but the velocity of this flow cannot be measured thus one should use the continuous wave Doppler this procedure allows one to measure the peak velocity of systolic blood flow through the aortic valve and to calculate the maximal pressure gradient if the aortic regurgitation is present the regurgitant jet can be mapped with a pulsed Doppler sample volume or it can be seen with color flow Doppler imaging from the apical for chamber view one should rotate the transducer about 120 degrees counterclockwise in order to obtain an apical long axis view of the left ventricle or the so called 3 chamber view an alternative method of obtaining this image is to initially obtain parasternal long axis view of the left ventricle then one must move the transducer onto the apex of the heart without changing its orientation in this image one can easily evaluate the mitral and aortic valves one has an optimal view of the left ventricular outflow tract one can also check the direct continuance of the inferior wall of the aorta in the anterior mitral leaflet and the superior wall of the aorta in the interventricular septum this is important for assessing the patients with congenital anomalies of the heart in this position of the scanning plane one obtains a cross-section through the anterior part of the interventricular septum that receives blood from the left anterior descending artery on the left side of the image one can see the posterior lateral wall of the left ventricle which receives blood from the circumflex artery or the right coronary artery from the apical for chamber view one should rotate the transducer about 60 to 70 degrees counterclockwise and tilt the scanning plane more laterally in order to obtain the apical to chamber view in this image one can see the left atrium the mitral valve the anterior left ventricular wall on the right side of the screen and the inferior left ventricular wall on the left side of the screen in this image one should observe the contractility of the true anterior and inferior left ventricular walls this two chamber view was taken from a post myocardial infarction patient and demonstrates an aneurysm in the basal inferior wall an apical view allows one to diagnose the congenital heart malformations in adults and children two to assess the regional wall motion abnormalities in patients with coronary artery disease three to perform a complete evaluation of mitral a or tick and tricuspid valves subcostal views you the transducer should be placed horizontally in the epigastric region and the scanning plane angled upwards towards the head to obtain images of the heart structures or downwards to obtain images of the major vessels these vessels are the abdominal aorta and inferior vena cava one can also see the hepatic veins as they enter into the inferior vena cava initially with the subcostal approach one obtains the four chamber view the scanning plane is directed horizontally and perpendicular to the patient’s axis after this one should angle it upwards when the angle between the transducer and the frontal plane is approximately 30 to 40 degrees one obtains four chambers on the screen in most patients one cannot see the apex of the heart with this approach if one angles the scanning plane a

little more upwards the image of the aorta a subcostal five chamber view will be obtained in this image one can see the aortic valve in those patients in whom or one could not see it when the other approaches were used due to obesity narrow intercostal spaces and fuzzy ma when one uses the subcostal approach ultrasonic beams are not parallel to the interatrial septum as opposed to the apical approach in a subcostal for chamber view the direction of ultrasonic beams is almost perpendicular to the interatrial septum thus in this approach one can very easily see the interatrial septum and diagnose its defect the subcostal short axis view is achieved by rotating the transducer orientation position to the 12 o’clock position in this image one can see the heart by the short axis view a subcostal approach allows visualization of the inferior vena cava in long axis one should place the transducer in the epigastric region and angle the scanning planes sagittal II on the middle line and then tilt it a little to the right inferior vena cava is seen posterior Li to the liver one can see the place where the inferior vena cava connects with the right atrium and sometimes with the valve at this Junction after inhalation the inferior vena cava partially collapses and after exhalation it dilates because of an increase of intrathoracic pressure if one rotates the transducer clockwise and angles it so that one can look under the right scapula one will see the area where the hepatic veins connect with the inferior vena cava hepatic veins are not positioned in the same plane so one will not see all three veins at the same time you if one places the transducer in the epigastric area and the scanning plane is directed sagittal E and then angled to the left one will obtain the image of the abdominal aorta in long axis one can see characteristic a aortic pulsations and anteriorly see the superior mesenteric artery that branches from the aorta after branching from the aorta the superior mesenteric artery immediately descends parallel to the aorta suprasternal approach you one should place the transducer in the suprasternal notch angle the scanning plane inferiorly and parallel to the aortic arch so that the scanning plane is directed from the anterior right to the posterior left in order to facilitate this manoeuvre one can place a pillow under the patient’s neck one will obtain a suprasternal long axis view of the aortic arch on the left side of the screen one can see an ascending aorta on the right the initial part of a descending aorta under the horizontal part of the aortic arch one can see the right pulmonary artery in cross-section in many patients one can see major vessels that branch from the aortic arch the brachiocephalic trunk the left common carotid artery the left subclavian artery if one angles the scanning plane a little anteriorly and rotates it a little to the right one can see the ascending aorta together with the aortic valve

from the suprasternal long axis view of the aortic arch one should rotate the transducer clockwise until the cross-section of the aortic arch is obtained you in this image a horizontal part of the aortic arch is shaped like a ring to the left of the ring one can see the superior vena cava the horizontal tube like structure under the aortic arch is the right pulmonary artery in long axis going deeper from the pulmonary artery one can see the left atrium if one places the transducer in the right supraclavicular pit and angles the scanning plane inferiorly one can see the superior vena cava in all its length from the connection of the brachiocephalic veins to the entrance of the superior vena cava into the right atrium you

You Want To Have Your Favorite Car?

We have a big list of modern & classic cars in both used and new categories.