Dr.

IOANA PETRE
Clinical Emergency Hospital, Bucharest
Carol Davila University of Medicine and Pharmacy, Bucharest
 ULTRASOUND (US)
 The image is formed as a result of the reflection
phenomenon of the ultrasound beam (US)
-Piezolelectric crystals

The principle of ultrasound imaging

1 2 3
Send ultrasound waves Analyze reflected
Create image
To the tissue being studied Ultrasound waves
General characteristics
- Continuation of the clinical examination

- Assess the structural, functional and hemodynamic

abnormalities of the heart

- Non-invasive, repeatable, portable equipment

- General use of the method-widely available

- New techniques used

VERY IMPORTANT!
 The complete examination is the one that is done
systematically, analyzing all the visible structures in each
Section

 The analysis is done according to an algorithm that must

be respected every time

 Don't forget to mount the electrodes for the ECG

Exception: emergencies!
Types of echocardiography
 Transthoracic echocardiography

 Tranesophageal echocadiography

 Exercise stress echocardiography

 Echocardiography in resyncronization therapy

 Contrast echcardiography
 Ultrasound techniques
 M mode

 2D cardiac ultrasound

 Doppler ultrasound

 Tissue Doppler ultrasound

 3D ultrasound

 Strain imaging
 Transthoracic echocardiography -2D

Simple and quick examination, but

- the patient can be a limiting factor (emphysema,

obesity, habitus, positioning)

- lack of visualization of some structures (left atrium

appendage, descending thoracic aorta)
 2D Echocardiography
Standard Windows/Views
Patient positioning - left lateral decubitus and dorsal
decubitus.
2D sections in real time
Scanning from 4 standard windows:
- parasternal
- apical
- subcostal
- Suprasternal
!!!The best 2D echo image is obtained when the US beam
is perpendicular to the structure to be examined
 Parasternal views
 Two types of sections:

-Long axis sections: sagittal (apex → base)

- Short axis sections: transverse ("slices of bread")

Long axis parasternal view(PLAX)
Long axis parasternal view
MEASUREMENTS IN M-MODE
 Parasternal short axis view(SAX)
By rotating 90 degrees clockwise from the position of
the probe in the parasternal long axis:

4 positions:
At the level of large vessels
At the level of the mitral valve
At the level of the papillary
muscles
At the apex
Short axis parasternal view at the level
of great vessels
Short axis at the level of great
vessels
Short axis parasternal view at
mitral valve
Short axis parasternal section at the level
of the papillary muscles
Short axis parasternal section al
the apex
 Apical views
 The patient in left lateral half-decubitus, the transducer is
placed as posterior as possible in general in the space 5th left
intercostal space on the anterior axillary line

- Apical 4ch view

- Apcial 5ch view
- Apical 2 ch view
- Apical 3ch view
Apical 4 chamber view
Apical 5 chamber view
Apical 2 chamber view
Apical 3 chamber view
Suprasternal view
Subcostal view
 Doppler ultrasound
 Doppler effect: the sound frequency increases as the
source approaches the observer and decreases as it moves
away

- source: red blood cell reflecting the ultrasound emitted by

the transducer
- the speed of the blood flow derives from the difference in
frequency between the transmitted and the reflected sound
HEMODYNAMIC ASSESSMENT=FUNCTIONAL EVALUATION
COLOR DOPPLER
Non-invasive visualization of blood flow
encoded in red, blue, and combinations thereof,
depending on: speeds, direction, turbulence
DOPPLER COLOR CODE

The blue flow is moving away from the transducer

The red flows to the transducer

 SPECTRAL DOPPLER
 Graphic recording of velocities in the form of flow curves
- speeds → pressure gradients
 EVALUATION OF LEFT
VENTRICULAR FUNCTION
-systolic function-
LV systolic function= pump function of the heart=LV myocardial
thickening

Global function: LV shape and volume

Regional function: contractility (kinetics) of different

segments
 EVALUATION OF THE GLOBAL
SYSTOLIC FUNCTION
- EJECTION FRACTION

LV EF = (enddiastolic LV vol – endsystolic LV vol/ enddiastolic LV vol) X

100 (%)
(stroke -volume as a percentage of enddiastolic volume)

SIMPSON METHOD

NORMAL>55%
 EVALUATION OF THE REGIONAL
SYSTOLIC FUNCTION
LV: - 3 levels (basal, middle, apical)
- 17 segments

Contractility score:
1 (normokinetic)
2 (hypokinetic)
3 (akinetic)
4 (diskinetic)
5 (aneurysm)

Kinetic score => sum of scores / number of segments

viewed (extension of regional anomalies)
Regional coronary segmentation-
parasternal views
Regional coronary segmentation-
apical views
 DIASTOLIC FUNCTION
- Allows adequate filling of LV at rest and exertion without
abnormal increase in diastolic pressure

- Events:
- Myocardial relaxation → ↓ rapid pression LV <LA,
mitral opening, rapid filling (~ 80%)
- Increases LV pressure, ↓ mitral flow rate => LA-LV
equalization (diastasis)
- Atrial systole: 15-20% filling (depends on LV
compliance, LV and LA pressure)
 Evaluation of RV function
- Predominantly longitudinal axis contractility
- TAPSE (Tricuspid Annulus Plan Systolic Excursion)
N > 16 mm
N > 16 mm
Tricuspid valve color Doppler
Tricuspid
Dopplervalve Spectral
continuu Doppler
la valva tricuspida
How to calculate the pressure in the pulmonary
artery?
How to estimate the pressure in the
right atrium?
Transesophageal ultrasound
- semi-invasive technique (local anesthesia)
- removes the patient's limiting factors
- excellent visualization of all cardiac structures
- utility in atrial thrombosis, congenital malformations,
endocarditis, valvulpathies, valvular prosthesis, procedures,
+-aortic dissection
 Echocardiography in emergencies
Acute myocardial infarction complications:
- Acute mitral regurgitation
- VSD
- Rupture of ventricular free wall

Aortic dissection
PE
Contrast echocardiography
 Improves the quality of images
 Identifies cardiac shuts
1.CONTRAST ECHOCARDIOGRAPHY USING
AGITATED SALINE CONTRAST--→ right chambers

2. CONTRAST ECHOCARDIOGRAPHY USING LEFT

VENTRICULAR OPACIFICATION AGENTS → left
chambers