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The ESC Textbook of
Cardiovascular Imaging
EUROPEAN SOCIETY OF CARDIOLOGY PUBLICATIONS
The ESC Textbook of Cardiovascular Medicine (Third Edition)
Edited by A. John Camm, Thomas F. Lüscher, Gerald Maurer, and Patrick W. Serruys
The ESC Textbook of Preventive Cardiology
Edited by Stephan Gielen, Guy De Backer, Massimo Piepoli, and David Wood
The EHRA Book of Pacemaker, ICD, and CRT Troubleshooting: Case-​based learning with multiple choice questions
Edited by Harran Burri, Carsten Israel, and Jean-​Claude Deharo
The EACVI Echo Handbook
Edited by Patrizio Lancellotti and Bernard Cosyns
The ESC Handbook of Preventive Cardiology: Putting prevention into practice
Edited by Catriona Jennings, Ian Graham, and Stephan Gielen
The EACVI Textbook of Echocardiography (Second Edition)
Edited by Patrizio Lancellotti, José Luis Zamorano, Gilbert Habib, and Luigi Badano
The EHRA Book of Interventional Electrophysiology: Case-​based learning with multiple choice questions
Edited by Hein Heidbuchel, Matthias Duytschaever, and Harran Burri
The ESC Textbook of Vascular Biology
Edited by Robert Krams and Magnus Bäck
The ESC Textbook of Cardiovascular Development
Edited by José Maria Pérez-​Pomares and Robert Kelly
The EACVI Textbook of Cardiovascular Magnetic Resonance
Edited by Massimo Lombardi, Sven Plein, Steffen Petersen, Chiara Bucciarelli-​Ducci, Emanuela R. Valsangiacomo Buechel, Cristina Basso,
and Victor Ferrari
The ESC Textbook of Sports Cardiology
Edited by Antonio Pelliccia, Hein Heidbuchel, Domenico Corrado, Mats Börjesson, and Sanjay Sharma
The ESC Handbook of Cardiac Rehabilitation
Edited by Ana Abreu, Jean-​Paul Schmid, and Massimo Piepoli
The ESC Textbook of Intensive and Acute Cardiovascular Care (Third Edition)
Edited by Marco Tubaro, Pascal Vranckx, Eric Bonnefoy-Cudraz, Susanna Price, and Christiaan Vrints
The ESC Textbook of Cardiovascular Imaging (Third Edition)
Edited by José Luis Zamorano, Jeroen J. Bax, Juhani Knuuti, Patrizio Lancellotti, Fausto J. Pinto, Bogdan A. Popescu, and Udo Sechtem
The ESC Textbook of
Cardiovascular
Imaging
THIRD EDITION

EDITED BY
José Luis Zamorano
Jeroen J. Bax
Juhani Knuuti
Patrizio Lancellotti
Fausto J. Pinto
Bogdan A. Popescu
Udo Sechtem

1
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Third Edition published in 2021
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 ​Preface
With great pleasure we would like to introduce the third edition
of The ESC Textbook of Cardiovascular Imaging. Cardiovascular
imaging is the cornerstone of non-​invasive diagnosis in cardi-
ology. The continuous development of all techniques implies the
need for continuous medical education.
The third edition of The ESC Textbook of Cardiovascular Imaging
includes new and updated chapters that explain the utility of the
different imaging modalities in the diagnosis of all relevant and
major cardiovascular diseases.
The clinically oriented text is accompanied by images and in-
sights of the everyday practice of these techniques, prepared by
experienced and well-​known cardiovascular imagers who have
dedicated long hours and commitment to prepare the chapters
included in this edition.
We hope that cardiologists, trainees, and cardiovascular
imagers find in this book the knowledge and expertise to cope
with the challenges faced in their daily practice.
As editors, we have tried to harmonize all chapters in order
to obtain an easy reading of all chapters. Images were carefully
selected to better understand the text. On behalf of all the edi-
tors, we would like to express our gratitude to all authors and
to Claudia Balseca as Editors’ Assistant. All of them worked ex-
tremely hard to make this third book possible.
We want to dedicate our work to the victims of COVID-​19
and their families, especially to our beloved friend Prof Maurizio
Galderisi, who was a co-​author in this book.
José Luis Zamorano
Jeroen J. Bax
Juhani Knuuti
Patrizio Lancellotti
Fausto J. Pinto
Bogdan A. Popescu
Udo Sechtem
 Free personal online access
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 Contents
Symbols and abbreviations xi
Contributors xv
SECTION 1
Technical aspects of imaging
1 Conventional echocardiography—​basic
principles 3
Andreas Hagendorff, Stephan Stobe,
and Bhupendar Tayal
2 Nuclear cardiology (PET and SPECT)—​basic
principles 41
Danilo Neglia, Riccardo Liga, Stephan G. Nekolla,
Frank M. Bengel, Ornella Rimoldi,
and Paolo G. Camici
3 Cardiac CT—​basic principles 57
Gianluca Pontone and Filippo Cademartiri
4 CMR—​basic principles 67
Jan Bogaert, Rolf Symons, and Jeremy Wright
5 Training and competence in cardiovascular
imaging 79
Kevin Fox and Marcelo F. Di Carli
SECTION 2
New technical developments in imaging
techniques
6 New developments in echocardiography/​
Advanced echocardiography 87
6.1 Three-​dimensional echocardiography   87
Silvia Gianstefani and Mark J. Monaghan
6.2 Assessment of myocardial function by
speckle-​tracking echocardiography   103
Thor Edvardsen, Lars Gunnar Klaeboe, Ewa Szymczyk,
and Jarosław D. Kasprzak
7 Contrast echocardiography 111
Roxy Senior, Harald Becher, Fausto J. Pinto,
and Rajdeep S. Khattar
8 Echocardiography in the cath lab: Fusion imaging
and use of intracardiac echocardiography 121
Covadonga Fernández-​Golfín and José Luis Zamorano
9 New technical developments in nuclear cardiology
and hybrid imaging 129
Antti Saraste, Sharmila Dorbala, and Juhani Knuuti
10 New technical developments in Cardiac CT:
Anatomy, fractional flow reserve (FFR), and
machine learning 145
Stephan Achenbach, Jonathan Leipsic, and James Min
SECTION 3
Valvular heart disease
11 Aortic valve stenosis 161
Philippe Pibarot, Helmut Baumgartner,
Marie-​Annick Clavel, Nancy Côté, and Stefan Orwat
12 Aortic valve regurgitation 181
Julien Magne and Patrizio Lancellotti
13 Mitral valve stenosis 191
Ferande Peters and Eric Brochet
14 Mitral valve regurgitation 199
Daniel Rodríguez Muñoz, Kyriakos Yiangou,
and José Luis Zamorano
viii C onte n ts
15 Tricuspid and pulmonary valve disease 211
Denisa Muraru and Elif Leyla Sade
16 Multiple and mixed valvular heart disease
Philippe Unger and Madalina Garbi
17 Intraoperative transoesophageal
echocardiography for valvular surgery 233
Joseph F. Maalouf and Hector I. Michelena
18 Valvular prostheses 251
Luigi P. Badano and Denisa Muraru
19 Endocarditis 271
Daniel Rodríguez Muñoz and Álvaro Marco del Castillo
SECTION 4
Procedures in the intensive
cardiovascular care unit
20 Imaging- guided transseptal puncture and
transcatheter closure of patent foramen ovale/
atrial septal defect, ventricular septal defect, and
paravalvular leaks 287
Itzhak Kronzon, Juan Manuel Monteagudo,
Francesco F. Faletra, Priti Mehla, and Muhamed Saric
21 Imaging for electrophysiological procedures 303
Louisa O’Neill, Iain Sim, John Whitaker, Steven Williams,
Henry Chubb, Pál Maurovich-​Horvat, Mark O’Neill,
and Reza Razavi
22 Transcatheter aortic valve implantation 315
Arnold C.T. Ng, Victoria Delgado, and Jeroen J. Bax
23 Transcatheter mitral valve interventions 337
Nina C. Wunderlich, Robert J. Siegel, Ronak Rajani,
and Nir Flint
24 Transcatheter tricuspid valve repair/​
replacement 361
Rebecca T. Hahn
25 Transcatheter pulmonic valve replacement
Kuberan Pushparajah and Alessandra Frigiola
SECTION 5
Coronary artery disease
26 Echocardiography and detection of coronary
artery disease 395
Thor Edvardsen, Marta Sitges, and Rosa Sicari
27 Nuclear cardiology and detection of coronary
artery disease 403
Richard Underwood, James Stirrup, and Danilo Neglia
223
28 PET-​CT and detection of coronary artery
disease 421
Marcelo F. Di Carli
29 MDCT and detection of coronary artery
disease 435
Stephan Achenbach and Pál Maurovich-​Horvat
30 CMR and detection of coronary artery
disease 447
Eike Nagel, Juerg Schwitter, and Sven Plein
31 Non-invasive Imaging of the vulnerable
atherosclerotic plaque 467
Rong Bing, David E. Newby, Jagat Narula,
and Marc R. Dweck
32 Imaging of microvascular disease 481
Paolo G. Camici and Ornella Rimoldi
SECTION 6
Heart failure
33 Evaluation of systolic LV function and
LV mechanics 497
Rainer Hoffmann and Frank A. Flachskampf
34 Evaluation of left ventricular diastolic
function 507
Bogdan A. Popescu, Carmen C. Beladan, and
Maurizio Galderisi†
35 Imaging of the right heart 519
Lawrence Rudski, Petros Nihoyannopoulos, and
Sarah Blissett
36 Assessment of viability 545
Luc A. Pierard, Paola Gargiulo, Pasquale Perrone-​Filardi,
Bernhard Gerber, and Joseph B. Selvanayagam
377
37 Imaging cardiac innervation 565
Albert Flotats and Ignasi Carrió
38 Cardiac resynchronization therapy: Selection of
candidates 577
Victoria Delgado and Jens-​Uwe Voigt
39 Cardiac resynchronization therapy: Optimization
and follow-​up 587
Marta Sitges and Erwan Donal

40 Echocardiography evaluation in extracorporeal
support 599
Susanna Price and Alessia Gambaro
41 Cardiac imaging in cardio-​oncology 613
Riccardo Asteggiano, Patrizio Lancellotti,
Maurizio Galderisi†, Stephane Ederhy, and Marie Moonen
SECTION 7
Cardiomyopathies
42 Hypertrophic cardiomyopathy 629
Nuno Cardim, Alexandra Toste, and Robin Nijveldt
43 Infiltrative cardiomyopathy 645
Massimo Lombardi, Silvia Pica, Antonella Camporeale,
Alessia Gimelli, and Dudley J. Pennell
44 Dilated cardiomyopathy 661
Upasana Tayal, Sanjay Prasad, Tjeerd Germans,
and Albert C. van Rossum
45 Other genetic and acquired
cardiomyopathies 681
Kristina Haugaa and Perry Elliott
SECTION 8
Peri-​myocardial disease
46 Pericardial effusion and cardiac tamponade 697
Allan Klein, Bernard Cosyns, and Aldo L. Schenone
47 Constrictive pericarditis 707
Alida L.P. Caforio, Maurizio Galderisi†, Massimo Imazio,
Renzo Marcolongo, Yehuda Adler, and Ciro Santoro
C on t e n ts ix
48 Myocarditis 715
Ali Yilmaz, Heiko Mahrholdt, and Udo Sechtem
49 Cardiac masses and tumours 731
Teresa López-​Fernández and Peter Buser
SECTION 9
Aortic disease: aneurysm and
dissection
50 The role of echocardiography 747
Arturo Evangelista and Gisela Teixidó-​Turà
51 Aortic disease: Aneurysm and dissection—​role
of CMR 757
Jose F. Rodriguez-​Palomares and Arturo Evangelista
52 Aortic disease: Aneurysm and dissection—​role
of MSCT 771
Rocío Hinojar and Raimund Erbel
SECTION 10
Adult congenital heart disease
53 The role of echocardiography in adult
congenital heart disease 783
Lindsay A. Smith, Mark K. Friedberg,
and Luc Mertens
54 The role of CMR and MSCT 809
Giovanni Di Salvo and Francesca R. Pluchinotta
Index 823
 Symbols and abbreviations

z video CMR cardiac magnetic resonance

E cross reference CPT cold pressure testing
9 additional online material CRT cardiac resynchronization therapy
M website CSA cross-​sectional area
AC arrhythmogenic cardiomyopathy/​attenuation CT computed tomography
correction CTA computed tomography angiography
AccT acceleration time CTCA computed tomography coronary angiography
ACE angiotensin-​converting enzyme CTP computed tomography myocardial perfusion
ACR American College of Radiology CW colour wave/​continuous wave
ACS acute coronary syndromes CWD colour wave Doppler
AF atrial fibrillation CZT cadmium zinc telluride
åICD implantable cardioverter defibrillator DECT dual-​energy computed tomography
Ar atrial re­verse velocity DOPS Direct Observation of Practical Skills
AR aortic regurgitation DSCT dual-​source computed tomography
ARVC arrhythmogenic right ventricular DSE dobutamine stress echocardiography
cardiomyopathy EACTS European Association for Cardio-​Thoracic
AS aortic stenosis Surgery
ASD atrial septal defect EACVI European Association of Cardiovascular
ASE American Society of Echocardiography Imaging
ASO amplatzer septal occluder EAM electro-​anatomical mapping
AV aortic valve/​atrial valve EANM European Association of Nuclear Medicine
AVA aortic valve area EAPC European Association of Preventive Cardiology
AVS aortic valve stenosis ECMO extracorporeal membrane oxygenation
BAV bicuspid aortic valve ECNC European Council of Nuclear Cardiology
BMI body mass index ECV extracellular volume
BNP B-​type natriuretic peptide ED effective radiation dose
BSA body surface area ED external diameter
CAC coronary artery calcium EDIC Echo Dobutamine International Cooperative
CAD coronary artery disease EDT E wave decel­eration time
CAV cardiac allograft vasculopathy EDV end-​diastolic volume
CBF coronary blood flow EF ejection fraction
CCT cardiac computed tomography EOA effective orifice area
CCTA coronary computed tomography angiography EPIC Echo-​Persantine International Cooperative
CFR case fatality rate/​coronary flow reserve ERO effective regurgitant orifice
CHF congestive heart failure EROA effective regurgitant orifice area
CIED cardiac implantable electrical devices ESC European Society of Cardiology
CLT Classroom and Laboratory Training ESCR European Society of Cardiac Radiology
CM contrast material ESCR European Society of Cardiovascular Radiology
CMD coronary microvascular dysfunction ESV end-​systolic volume
xii Symb ols an d Abbreviations

EVEREST Endovascular Valve Edge-​to-​Edge REpair Study MAD mitral annular disjunction
FAC fractional area change MAPSE mitral annular plane systolic excursion
FBP filtered back-​projection MBF myocardial blood flow
FF forward flow MCE myocardial contrast echocardiography
FFA free fatty acid MCQ multiple choice question
FFR fractional flow reserve MDCT multidetector-​row computed tomography
FO fossa ovalis MESA Multi-​Ethnic Study of Atherosclerosis
FOV field of view MFR myocardial flow reserve
FWLS free wall longitudinal strain MI mechanical index
GCV GREAT cardiac vein MI myocardial infarction
GLS global longitudinal left ventricular strain MIP maximum intensity projections
GLS global longitudinal strain MPI myocardial performance index/​myocardial
HCM hypertrophic cardiomyopathy perfusion imaging
HF heart failure MPRI myocardial perfusion reserve index
HFA Heart Failure Association MR mitral regurgitation
HFpEF heart failure with preserved ejection fraction MRA magnetic resonance angiography
HLA horizontal long axis MRCA magnetic resonance coronary angiography
HR heart rate MRI magnetic resonance imaging
HU Hounsfield Units MS mitral stenosis
HVD heart valve disease MV mitral valve
IAEA International Atomic Energy Agency MVA mitral valve area
ICA invasive coronary angiography MVO microvascular obstruction
ICU intensive care unit NASCI North American Society for Cardiovascular
IDR iodine delivery rate Imaging
INCAPS IAEA Nuclear Cardiology Protocols NBE National Board of Echocardiography
Cross-​Sectional Study NMR nuclear magnetic resonance
IOD internal orifice diameter NYHA New York Heart Association
IRIS iterative reconstruction in image space OCT optical coherence tomography
IVC inferior vena cava OR operating room
IVRT isovolumic relaxation time PA pulmonary artery
IVUS intravascular ultrasound PAH pulmonary arterial hypertension
LA left atrium PAP pulmonary arterial pressure
LA long axis PASP pulmonary artery systolic pressure
LAA left atrial appendage PCWP pulmonary capillary wedge pressure
LAD left anterior descending PE pulmonary embolism
LAP left atrial pressure PET positron emission tomography
LAV left atrial volume PFO patent foramen ovalis
LAVi LA volume indexed to body surface area PH pulmonary hypertension
LBBB left bundle branch block PHT pressure half-​time
LD left disc PISA proximal isovelocity surface area
LDL low-​density lipoprotein PIV posterior interventricular vein
LGE late gadolinium enhancement PLARC paravalvular Leak Academic Research
LMV left marginal vein Consortium
LOR line-​of response PPL referred to as periprosthetic leak
LS longitudinal strain PR pulmonary regurgitation
LV left ventricle PS pulmonary stenosis
LVAD left ventricular assistance device PSF point spread function
LVFP left ventricular filling pressure PSIR phase-​sensitive inversion recovery
LVEDD left ventricle end-​diastolic dimension PSS post-​systolic shortening
LVEDP left ventricular end-diastolic pressure PV pulmonary valve
LVEF left ventricular ejection fraction PVI pulmonary vein isolation
LVESV left ventricular end-​systolic volume PVLV posterior vein of the left ventricle
LVOT left ventricular outflow tract PVR pulmonary vascular resistance
MACE major adverse cardiovascular events PW pulsed wave
 Sym b ol s a n d A b b rev iat i on s xiii

QA quality assurance STE speckle tracking echocardiography

RA right artery SV stroke volume
RAP right atrial pressure SVC superior vena cava
RCA right coronary artery TA tricuspid annular
RD right disc TAC time-​activity curves
RF regurgitant flow TAD tissue annulus diameter
RF regurgitant fraction TAPSE tricuspid annular plane systolic excursion
RIMP right-​sided index of myocardial performance TAVI transcatheter aortic valve implantation
ROI region of interest TAVR transcatheter aortic valve replacement
ROS reactive oxygen species TOE transoesophageal echocardiography
RPM revolutions per minute TI the optimal inversion
RV right ventricle TOF tetralogy of Fallot
RVAD right ventricular assist device TOF time of flight
RVEF right ventricular ejection fraction TR tricuspid regurgitation
RVOT right ventricular outflow tract TTDE the feasibility of transthoracic doppler
RVSP right ventricular systolic pressure echocardiography
SAM systolic anterior motion TV tricuspid valve
SARF severe acute respiratory failure USPIO ultrasmall superparamagnetic iron oxide
SCCT Society of Cardiovascular Computed VA ventricular arrhythmias
Tomography VAD ventricular assist device
SCD sudden cardiac death VC vena contracta
SCMR Society for Cardiovascular Magnetic Resonance VHD valvular heart disease
SD standard deviation VLA vertical long axis
SE stress echocardiography VSD ventricular septal defect
SHD structural heart disease VT velocity time
SL septal leaflet VT ventricular tachycardia
SNR signal-​to-​noise ratio VTI velocity-​time integral
SPAMM spatial modulation of magnetization WISE Women’s Ischemia Syndrome Evaluation
SPECT single photon emission computed tomography
SRD sewing ring diameter
SSFP steady-​state free precession
 Contributors
Stephan Achenbach
Department of Cardiology, Friedrich-Alexander University
Erlangen-Nürnberg, Erlangen, Germany
Yehuda Adler
The Gertner Institute, Sheba Medical Center, affiliated to
Sackler Medical School, Tel Aviv University and the College for
Academic Studies, Tel Aviv, Israel
Riccardo Asteggiano, MD, FESC
Adjunct Professor, Faculty of Medicine, Insubria University,
Varese, Italy; LARC (Laboratorio Analisi e Ricerca Clinica),
Turin, Italy
Luigi P. Badano, MD, PhD, FESC, FACC, Honorary FASE,
Honorary FEACVI
Professor of Cardiovascular Medicine, University of Milano-​
Bicocca; Director of the Cardiovascular Imaging Unit,
Department of Cardiovascular, Neural and Metabolic Sciences;
Istituto Auxologico Italiano, IRCCS, Milano, Italy; Istituto
Auxologico Italiano, IRCCS, Cardiology Unit, Department
of Cardiovascular, Neural and Metabolic Sciences, San Luca
Hospital, and Department of Medicine and Surgery, University
of Milano-​Bicocca, Piazzale Brescia, MI, Italy
Helmut Baumgartner, MD
Department of Cardiology III, Adult Congenital and Valvular
Heart Disease, University Hospital Muenster, Muenster, Germany
Jeroen J. Bax, MD, PhD
Professor of Cardiology, Head Department of Non-invasive
Imaging, Leiden University Medical Center, The Netherlands
Harald Becher, MD, PhD, FRCP
Professor of Medicine, ABACUS, Mazankowski Alberta
Heart Institute, University of Alberta Hospital, Edmonton,
Alberta, Canada
Carmen C. Beladan, MD, PhD
University of Medicine and Pharmacy ‘Carol Davila’—​
Euroecolab, Emergency Institute for Cardiovascular Diseases
‘Prof. Dr. C. C. Iliescu’, Bucharest, Romania
Frank M. Bengel, MD, Univ. Prof. Dr. med.
Director, Department of Nuclear Medicine, Hannover Medical
School, Hannover, Germany
Rong Bing, MBBS
Doctor, Department of Centre for Cardiovascular Science,
University of Edinburgh, Edinburgh, UK
Sarah Blissett, MD, MHPE
Cardiologist, London Health Sciences Centre, London, Canada;
Assistant Professor (Medicine), Western University, London,
Canada; Researcher, Centre for Education Research and
Innovation, Schulich School of Medicine and Dentistry, Western
University, London, Canada
Jan Bogaert, MD, PhD
Faculty of Medicine, Department of Imaging and Pathology,
University Hospitals Leuven, Leuven, Belgium
Eric Brochet
Department of Cardiology, University Hospital Bichat, Paris,
France
Peter Buser, MD
Department of Cardiology, University Hospital Basel, Basel,
Switzerland
Filippo Cademartiri, MD, PhD
Chairman Prof. Dr., Department of Radiology, Area Vasta 1—​
ASUR Marche, Urbino, PU, Italy
Alida L.P. Caforio, MD, PhD, FESC
Cardiologist, Department of Cardiac, Thoracic, Vascular
Sciences and Public Health, University of Padova, Padova, Italy
Paolo G. Camici, MD, FESC, FAHA, FACC, FRCP
Professor of Cardiology, Department of Cardiovascular Research
Center, San Raffaele Hospital and Vita Salute University,
Milan, Italy
Antonella Camporeale, MD, PhD
Multimodality Cardiac Imaging Section, I.R.C.C:S., Policlinico
San Donato, Milan, Italy
xvi C ontribu tors
Nuno Cardim, MD, PhD
Head Echo Lab, Department of Cardiology, Hospital da Luz,
Lisbon, Portugal
Ignasi Carrió, MD, FEBNM, FESC, FRCP
Professor of Nuclear Medicine, Universitat Autònoma de
Barcelona, Director, Nuclear Medicine Department, Hospital de
la Santa Creu i Sant Pau, Barcelona, Spain
Henry Chubb
Division of Pediatric Cardiology, Department of Pediatrics,
Stanford University, USA
Marie-​Annick Clavel, DVM, PhD
Associate Professor, Department of Medicine, Laval University,
Canada Research Chair on Women’s Valvular Heart Health,
Institut Universitaire de Cardiologie et de Pneumologie de
Québec, QC, Canada
Bernard Cosyns, MD, PhD, FESC, FEACVI
Cardiology Department, Centrum voor hart en vaatziekten,
Universitair ziekehuis Brussel, 101 laarbeeklaan 1090 Brussels,
Belgium
Nancy Côté, PhD
Institut Universitaire de cardiologie te de Pneumologie de
Québec, Québec, Canada
Álvaro Marco del Castillo, MD
Victoria Delgado, MD, PhD
Cardiologist, Department of Cardiology, Leiden University
Medical Center, Leiden, the Netherlands
Marcelo F. Di Carli, MD
Executive Director, Cardiovascular Imaging, Department of
Radiology and Medicine, Brigham and Women’s Hospital,
Boston, MA, USA, and Family Professor of Radiology and
Medicine, Women’s Hospital, Seltzer, Harvard Medical School,
Boston, MA, USA
Giovanni Di Salvo, MD, PhD, MSc, FESC, FEACVI, FISC
Professor and Director, Department of Paediatric Cardiology
and Congenital Heart Disease, University of Padua, Padua, Italy;
Honorary Consultant Royal Brompton Hospital, London, UK
Erwan Donal, MD, PhD
Cardiology & INSERM1099, University Hospital, University
Rennes-​1, France
Sharmila Dorbala, MD
Division of Nuclear Medicine, Department of Radiology,
Brigham and Women’s Hospital, Boston, MA, USA
Marc R. Dweck, MD, PhD
Professor, Department of BHF Centre for Cardiovascular
Science, University of Edinburgh, Edinburgh, UK
Stephane Ederhy
Department of Cardiology, AP-HP, Saint-Antoine Hospital,
Sorbonne University, Paris, France
Thor Edvardsen, MD, PhD
Professor, Department of Cardiology, Oslo University Hospital,
Oslo, Norway
Perry Elliott
Chair of Cardiovascular Medicine, University College London,
London, UK
Raimund Erbel, MD, FAHA, FESC, FASE, FACC
Medical Informatics, Biometry and Epidemiology, University
Clinic, Universitat Duisburg-Essen, Essen, Germany
Arturo Evangelista, MD, FESC
Institut de Recerca Vall d’Hebron (VHIR), Coordinator of
Valvular and Aortic Research Unit, Hospital Universitari Vall
d’Hebron, Barcelona, Spain
Francesco F. Faletra, MD
Director of Cardiac Imaging Service, Cardiocentro Ticino
Lugano, Switzerland
Covadonga Fernández-​Golfín, MD
Cardiac Imaging Unit Coordinator, Cardiology Department,
Ramón y Cajal University Hospital, Madrid, Spain
Frank A. Flachskampf, MD, FESC, FACC
Professor, Department of Medical Sciences, Uppsala University,
Uppsala, Sweden
Nir Flint, MD
Attending Cardiologist, Echocardiography Lab, Division of
Cardiology, Tel-​Aviv Sourasky Medical Center, Sackler Faculty
of Medicine, Tel-​Aviv University, Tel-​Aviv, Israel
Albert Flotats, MD
Consultant, Department of Nuclear Medicine, Hospital de la
Santa Creu i Sant Pau, Barcelona, Spain
Kevin Fox, MD, FRCP, FESC
Consultant Cardiologist, Department of Cardiology, Imperial
College Healthcare NHS Trust, London, Middlesex, UK
Mark K. Friedberg, MD
Professor, The Hospital for Sick Children, The University of
Toronto, Toronto, ON, Canada
Alessandra Frigiola, MD, MD(res), FRCP
Consultant Cardiologist—​ACHD specialist, Cardiovascular,
ACHD, Guy’s & St Thomas’ Hospital, NHS Foundation Trust,
London, UK
Maurizio Galderisi, MD†
Professor of Medicine, Department of Advanced Biomedical
Sciences, Federico II University Hospital, Naples, Italy
Alessia Gambaro, MD
Cardiology Division, Department of Medicine, University of
Verona, Verona, Italy
Madalina Garbi, MD, MA
Consultant Cardiologist, Department of Cardiology, Royal
Papworth Hospital, Cambridge, UK

Paola Gargiulo, MD, PhD
Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy
Bernhard Gerber, MD, PhD, FESC, FACC, FAHA
Professor of Medicine, Cardiology Division, Department of
Cardiovascular Diseases, Cliniques Universitaires St. Luc UC
Louvain, Brussels, Belgium
Tjeerd Germans, MD, PhD
Cardiologist, Department of Cardiology, Amsterdam University
Medical Center, Amsterdam, the Netherlands
Silvia Gianstefani, MD
Alessia Gimelli, MD
Fondazione Toscana Gabriele Monasterio, Pisa, Italy
Andreas Hagendorff, MD
Professor, Department of Cardiology, University Hospital
Leipzig, Leipzig, Germany
Rebecca T. Hahn, MD, FESC
Department of Medicine, Division of Cardiology/​New York
Presbyterian Hospital, New York-​Presbyterian/​Columbia
University Medical Center, New York, NY, USA
Kristina Haugaa, MD
Rocío Hinojar, MD
Ramón y Cajal University Hospital, Madrid, Spain
Rainer Hoffmann, MD
Professor, Department of Cardiology, Bonifatius Hospital
Lingen, Lingen, Germany
Massimo Imazio, MD, FESC
Multimodality Cardiac Imaging Section, IRCCS Policlinico San
Donato, Milan, Italy
Jarosław D. Kasprzak, MD, PhD
Professor of Medicine, Department and Chair of Cardiology,
Bieganski Hospital, Medical University of Lodz, Lodz, Poland
Rajdeep S. Khattar, DM, FRCP, FACC, FESC
Consultant Cardiologist and Honorary Clinical Senior Lecturer,
Royal Brompton and Harefield NHS Trust, and National Heart
and Lung Institute, Imperial College, London, UK
Lars Gunnar Klaeboe
Allan Klein, MD, FRCP(C), FACC, FAHA, FASE
Professor of Medicine, Cleveland Clinic Lerner College of
Medicine of Case Western Reserve University, ​Director, Center
for the Diagnosis and Treatment of Pericardial Diseases, Section
of Cardiovascular Imaging, Department of Cardiovascular
Medicine, Heart, Vascular, and Thoracic Institute, Cleveland
Clinic, Cleveland, OH, USA
Juhani Knuuti, MD, PhD, FESC
Turku PET Centre, Turku University Hospital and University of
Turku, Turku, Finland
C on t ri bu tor s xvii
Itzhak Kronzon, MD, FASE, FESC, FACC, FAHA, FCCP
Professor of Cardiovascular Medicine, Hofstra University,
NY, USA
Patrizio Lancellotti
Professor, Head of Department, Department of Cardiology,
University of Liège Hospital, Liège, Belgium
Jonathan Leipsic, MD, FRCPC, MSCCT
Physician, Department of Imaging and Cardiology, UBC,
Vancouver, BC, Canada
Riccardo Liga, MD, PhD
Cardiologist, Cardiothoracic and Vascular Department,
University Hospital of Pisa, Pisa, Italy
Massimo Lombardi, MD, FESC, PhD
Head, Multimodality Cardiac Imaging Section, I.R.C.C.S
Policlinico San Donato, Milan, Italy
Teresa López-​Fernández, MD
Senior Consultant Cardiologist, Department of Cardiology, La
PAz University Hospital, IdiPAZ Research Institue, Ciber CV,
Madrid, Spain
Joseph F. Maalouf, MD, FAHA, FACC, FASE
Professor of Medicine, Director of Interventional
Echocardiography, Consultant in Cardiovascular Diseases,
Department of Cardiovascular Medicine, Mayo Clinic,
Rochester, MN, USA
Julien Magne, PhD
Department of Cardiology, CHU de Limoges, Limoges, France
Heiko Mahrholdt
Professor Doctor, Head of Imaging, Department of Cardiology,
Robert Bosch Medical Center, Stuttgart, BW, Germany
Renzo Marcolongo, MD
Senior Staff Physician, Department of Medicine, Azienda
Ospedale Università Padova, Padova, Italy
Pál Maurovich-​Horvat, MD
Priti Mehla, MD
Lenox Hill Hospital, New York, NY, USA
Luc Mertens, MD, PhD
Professor of Paediatrics, Department of Cardiology, The
Hospital for Sick Children, University of Toronto, Toronto,
ON, Canada
Hector I. Michelena, MD, FACC, FASE, FESC
Professor of Medicine, Department of Cardiovascular Medicine,
Mayo Clinic, Rochester, MN, USA
James Min, MD
Mark J. Monaghan, PhD, FRCP (Hon), FACC, FESC
Director of Non-​Invasive Cardiology, King’s College Hospital,
Denmark Hill, London, UK
xviii C ontribu tors
Juan Manuel Monteagudo, MD
Department of Cardiology, University Hospital Ramón y Cajal,
Madrid, Spain
Marie Moonen, MD, PhD
University Hospital Sart Tilman, GIGA Cardiovascular Sciences,
Department of Cardiology, Liege, Belgium
Daniel Rodríguez Muñoz, MD, PhD
Consultant, Department of Cardiology, Hospital Universitario
12 de Octubre, Madrid, Spain
Denisa Muraru, MD, PhD, FESC, FACC, FASE
Department of Medicine and Surgery, University of Milano-
Bicocca, Istituto Auxologico Italiano, IRCCS, Milan, Italy
Eike Nagel, MD
Jagat Narula, MD, PhD, MACC
Philip J. and Harriet L. Goodhart Chair of Medicine, Professor
of Medicine, Radiology and Health System Design & Global
Health, Chief, Division of Cardiology, Mount Sinai Hospital
Morningside; Associate Dean for Global Health, Icahn School
of Medicine at Mount Sinai, Executive Editor, Journal of the
American College of Cardiology; Vice President Elect, World
Heart Federation, New York, NY, USA
Danilo Neglia, MD
Fondazione Toscana G. Monasterio, Via G. Moruzzi, Pisa, Italy
Stephan G. Nekolla, PhD, FESC
Adjunct Teaching Professor, Nuklearmedizinische Klinik und
Poliklinik, Klinikum rechts der Isar der Technischen Universität
München, and Deutsches Zentrum für Herz-​Kreislauf-​Forschung
e.V. Partner site Munich Heart Alliance, München, Germany
David E. Newby
Centre for Cardiovascular Science, University of Edinburgh,
Edinburgh, UK
Arnold C.T. Ng
Princess Alexandra Hospital, Brisbane, Queensland, Australia;
Faculty of Medicine, South Western Sydney Clinical School, the
University of New South Wales, Australia
Petros Nihoyannopoulos, MD
Robin Nijveldt, MD, PhD, FESC
Cardiologist, Department of Cardiology, Radboud University
Medical Center, Nijmegen, the Netherlands
Louisa O’Neill
King’s College London, UK; Guy’s and St Thomas NHS
Foundation Trust, London, UK
Mark O’Neill, MD
Stefan Orwat, MD
Consultant Cardiologist, Adult Congenital and Valvular Heart
Disease Department, University of Muenster, Muenster, Germany
Dudley J. Pennell, MD, FRCP, FACC, FESC, FRCR, FAHA,
FMedSci, FSCMR
National Heart and Lung Institute, Imperial College, Royal
Brompton and Harefield NHS Foundation Trust, London, UK
Pasquale Perrone-​Filardi
Department of Clinical Medicine, Cardiovascular and
Immunology Sciences, Federico II University, Naples, Italy
Ferande Peters, MBBCH, FCP (SA), FACC, FESC, FRCP
Senior Cardiologist, Associate Professor, Flora Hospital,
Cardiovascular Pathophysiology and Genomics Unit,
University of the Witwatersrand, Johannesburg, South Africa
Philippe Pibarot, DVM, PhD, FESC, FACC, FAHA, FCCS
Head of Cardiology Research, Department of Cardiology,
Institut Universitaire de Cardiologie et de Pneumologie de
Québec/​Québec Heart & Lung Institute, Laval University,
Québec, QC, Canada
Silvia Pica, MD
Multimodality Cardiac Imaging Section, I.R.C.C:S., Policlinico
San Donato, Milan, Italy
Luc A. Pierard, MD, PhD, FESC
Honorary Professor of Medicine, Department of Cardiology,
University of Liège, Liège, Belgium
Fausto J. Pinto, MD, PhD, FESC, FACC, FASE, FSCAI
Head of Department, Department of Cardiovascular Medicine,
University Hospital, Universidade de Lisboa, Lisbon, Portugal
Sven Plein, MD, PhD, FRCP
Professor, British Heart Foundation Professor of Cardiovascular
Imaging, Leeds Institute of Cardiovascular and Metabolic
Medicine, University of Leeds, Leeds, UK
Francesca R. Pluchinotta, MD
Consultant of Pediatric Cardiology and Adult Congenital Heart
Disease, Multimodality Cardiac Imaging Unit, IRCCS Policlinico
San Donato, Milan, Italy
Gianluca Pontone, MD, PhD
Director, Department of Cardiovascular Imaging, Centro
Cardiologico Monzino, IRCCS, Milan, Italy
Bogdan A. Popescu, MD, PhD, FESC, FACC
Professor of Cardiology, University of Medicine and Pharmacy
‘Carol Davila’—​Euroecolab, Head of Cardiology Department,
Emergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C.
Iliescu’, Bucharest, Romania
Sanjay Prasad, MD
Susanna Price, MD, PhD
Professor of Cardiology and Intensive Care, Adult Intensive Care
Unit, Royal Brompton Hospital, London, UK
Kuberan Pushparajah, MD

Ronak Rajani, BM, DM, FRCP, FESC, FSCCT, FACC
Department of Cardiology, Guy’s and St Thomas’ NHS
Foundation Trust, London, UK
Reza Razavi, MD
Ornella Rimoldi, MD
IBFM, Consiglio Nazionale delle Ricerche, Segrate, Italy
Jose F. Rodriguez-​Palomares, MD, PhD
Director of Cardiovascular Imaging Department, Department of
Cardiology, Vall Hebrón Hospital, Barcelona, Catalonia, Spain
Lawrence Rudski, MD, FRCPC
Director, Azrieli Heart Center, Jewish General Hospital, McGill
University, Montreal, QC, Canada
Elif Leyla Sade, MD
Professor of Cardiology, Department of Cardiology, Baskent
University, Ankara, Turkey
Ciro Santoro, MD
Department of Advanced Biomedical Science, Federico II,
University Hospital, Naples, Italy
Antti Saraste, MD, PhD, FESC
Professor, Chief Cardiologist, Heart Center, Turku University
Hospital, Turku, Finland
Muhamed Saric, MD, PhD
Director, Noninvasive Cardiology, Professor of Medicine,
Leon H. Charney Division of Cardiology, New York University
Langone Health, New York, NY
Aldo L. Schenone, MD
Chief Cardiovascular Imaging Fellow
Section of Non Invasive Cardiovascular Imaging,
Department of Radiology
Brigham and Women’s Hospital, Harvard Medical School,
Boston, MA, USA
Juerg Schwitter, MD
Full Professor, Cardiovascular Department, University Hospital
Lausanne, CHUV, Faculty of Biology and Medicine, Lausanne
University, Lausanne, VD, Switzerland
Udo Sechtem, MD
Associate Professor of Cardiology, Cardiologicum and Robert-​
Bosch-​Krankenhaus, Stuttgart, Germany
Joseph B. Selvanayagam, MD, PhD
Professor in Cardiovascular Medicine, Flinders University,
Adelaide, Australia
Roxy Senior, MD, DM, FRCP, FACC, FESC
Consultant Cardiologist and Professor of Cardiology, Department
of Cardiology, Royal Brompton Hospital, London, UK
Rosa Sicari, MD, PhD
Research Director, Department of Biomedicine, Institute of
Clinical Physiology, Pisa, PI, Italy
C on t ri bu tor s xix
Robert J. Siegel, MD, FACC
Kennamer Chair in Cardiac Ultrasound, Medical Director,
Clinic for Hypertrophic Cardiomyopathy and Aortopathies;
Director, Cardiac Noninvasive Laboratory; Professor of
Medicine, Cedars-​Sinai Medical Center and UCLA School of
Medicine, CA, USA
Iain Sim, MD
Clinical Research Fellow in Cardiology, King’s College
London, UK
Marta Sitges, MD, PhD
Director, Cardiovascular Institute, Hospital Clinic, Professor of
Medicine, University of Barcelona, Barcelona, Spain
Lindsay A. Smith
University Hospital Southampton, Southampton, UK
James Stirrup, DLM, MD(Res), FSCCT, FRCP
Consultant Cardiologist, Department of Cardiology, Royal
Berkshire NHS Foundation Trust, London, UK
Stephan Stobe, MD
Rolf Symons, MD, PhD
Department of Imaging and Pathology, Faculty of Medicine,
University Hospitals Leuven, KU Leuven, Leuven, Belgium
Ewa Szymczyk, MD
Bhupendar Tayal, MD
Upasana Tayal, MD
Gisela Teixidó-​Turà, MD, PhD, FESC
Vall d’Hebron Research Institute, Hospital Universitari Vall
d’Hebron, CIBER-​CV, Barcelona, Spain
Alexandra Toste, MD
Hospital da Luz, Inherited Cardiovascular Diseases &
Hypertrophic Cardiomyopathy Center, Affiliated Professor at
NOVA Medical School, Lisbon, Portugal
Richard Underwood, MA, DM, FRCP, FRCR
Emeritus Professor of Cardiac Imaging, National Heart and
Lung Institute, Imperial College London, London, UK
Philippe Unger, MD, PhD
Head of Department, Department of Cardiology, CHU Saint-​
Pierre, Université Libre de Bruxelles, Brussels, Belgium
Albert C. van Rossum, MD, PhD
Department of Cardiology, Amsterdam University Medical
Centers, Amsterdam, the Netherlands
Jens-​Uwe Voigt, MD, PhD, FESC
Head of Echocardiography, Department of Cardiovascular
Diseases, University Hospitals Leuven, Leuven, Belgium
John Whitaker
Division of Imaging Sciences and Biomedical Engineering,
King’s College, London, UK
xx C ontribu tors

Steven Williams Kyriakos Yiangou, MD, MSc, FESC, FACC, FEACVI

Division of Imaging Sciences and Biomedical Engineering,
King’s College, London, UK
Jeremy Wright, MBBS, FRACP
Cardiologist, Greenslopes Private Hospital, Brisbane, Australia
Nina C. Wunderlich, MD
Head of Noninvasive Cardiology, Department of Cardiology,
Cardiovascular Center Darmstadt, Darmstadt, Hessen, Germany
Cardiologist, President Cyprus Society of Cardiology
Ali Yilmaz, MD
Department of Cardiology, Division of Cardiovascular Imaging,
University Hospital Münster, Germany
José Luis Zamorano, MD, PhD
Head of Cardiology, University Hospital Ramon y Canal,
Madrid, Spain
 SECTION 1

Technical aspects of
imaging

1 Conventional echocardiography—​basic principles 3

Andreas Hagendorff, Stephan Stobe, and Bhupendar Tayal
2 Nuclear cardiology (PET and SPECT)—​basic principles 41
Danilo Neglia, Riccardo Liga, Stephan G. Nekolla, Frank M. Bengel, Ornella Rimoldi, and
Paolo G. Camici
3 Cardiac CT—​basic principles 57
Gianluca Pontone and Filippo Cademartiri
4 CMR—​basic principles 67
Jan Bogaert, Rolf Symons, and Jeremy Wright
5 Training and competence in cardiovascular imaging 79
Kevin Fox and Marcelo F. Di Carli

Contents
Introduction 3
Principles of transthoracic
echocardiography—​practical aspects 3
Principles of image optimization and
identification of artefacts—​practical
aspects 7
Standardized data acquisition in
transthoracic echocardiography 7
Principles of transoesophageal
echocardiography—​practical
aspects 24
Standardized data acquisition in
transoesophageal echocardiography 28
Standard values in transthoracic and
transoesophageal echocardiography 37
M-​mode measurements 37
Two-​dimensional measurements 38
Pulsed spectral Doppler measurements 38
Continuous wave Doppler measurements 38
Pulsed spectral tissue Doppler
measurements 38
Acknowledgements 40
CHAPTER 1
Conventional
echocardiography—​basic
principles
Andreas Hagendorff, Stephan Stobe,
and Bhupendar Tayal
Introduction
Echocardiography is an imaging technique that enables accurate assessment of car-
diac structures and cardiac function. Conventional echocardiography involves different
modalities—​especially the M-​mode, the 2D, and colour Doppler, as well as the pulsed-​
wave and continuous wave Doppler. The M-​mode illustrates the reflections of a single
sound beam plotted against time. 2D echocardiography enables the documentation of
views, which represent characteristic sectional planes of the moving heart during one
heart cycle. Colour Doppler echocardiography adds the information of blood flow to
the 2D cineloop. Pulsed-​wave Doppler is the acquisition of a local blood flow spectrum
of a defined region represented by the dimension of the sample volume, whereas con-
tinuous wave Doppler displays the blood flow spectrum of all measured blood flow vel-
ocities along a straight line sound beam from its beginning to the end. The handling of
the transducer has to be target-​oriented, stable with respect to the imaging targets, and
coordinated with respect to angle differences between the defined views to use all these
modalities correctly to get optimal image quality of the cineloops and spectra.
Thus, the focus of this chapter will be a mainly practically oriented description of scan-
ning technique in transthoracic and transoesophageal echocardiography.
The echocardiographic documentation requires image optimization and ultrasound
machines, which fulfil the international laboratory standards in echocardiography. Thus,
the equipment has to be minimally capable to enable broadband 2D imaging, M-​mode
imaging, pulsed and continuous wave Doppler, as well as colour-​coded imaging, pulsed
tissue Doppler imaging, and complete digital storage capability. In addition, the ultra-
sound system has to have all technical possibilities for transoesophageal, contrast, and
stress echocardiography. An electrocardiographic (ECG) recording should generally be
performed in order to be able to capture complete heart cycles according to the ECG
trigger. This chapter is written in accordance with the current international guidelines
and recommendations [1–​7].
Principles of transthoracic echocardiography—​
practical aspects
The main principle of echocardiographic scanning is an exact or best possible manual
control of the region of interest during the technical procedure. This principle includes
the ability to move a certain cardiac structure within the scan sector from the left to
the right and vice versa without losing the cardiac structures of the selected sectional
4 CHAPTER 1 C on v ent ional ech o cardio gr a phy — basi c pri n ci pl es
plane. In addition, this aspect is documented by the ability to ro-
tate the transducer exactly about 60 or 90° without losing the de-
fined cardiac structure in the centre of the primary scan sector
before rotating. In other words, the visualization of cardiac struc-
tures in the centre of the scan sector has to be combined with
the technical skill of the investigator to change only one plane
within the spatial coordinates to achieve accurate characteriza-
tion and documentation of the target cardiac structure. Thus, the
easy message of transthoracic echocardiography is scanning by
tilting without flipping and rotating, by flipping without tilting
and rotating, as well as by rotating without tilting and flipping.
This sounds easy, but it requires a stable transducer position next
to the skin of the patient, an absolutely stable guiding of the trans-
ducer, and a stereotactic manual control of the transducer.
Regarding these aspects it is surprising that the finger position
of holding a transducer has almost never been described in lec-
tures and books about echocardiography, whereas in every book
about musical instruments instructions of hand and finger posi-
tions, and illustrations of fingering charts are given.
In transthoracic echocardiography there is a complex inter-
action between the eyes, the brain, and the hand muscles to co-
ordinate looking to a monitor to detect incongruities between
the actual view and defined views and to correct them by manual
manoeuvres to get the standardized views. Thus, it is like ‘seeing’
the heart with your hands. A basic position of the transducer in
the hand is necessary to get the orientation for the scan procedure
for an easy, but controlled change of a sectional plane. This im-
plies that a defined holding of the transducer is always linked to a
Fig. 1.1 Correct relaxed holding of the transducer using the right hand. The transducer lies on the fourth and fifth finger without any muscle tension (a), the
pulp of the thumb only has contact to the notch of the transducer (b). The pulps of the fourth and fifth finger have contact to the skin (c) and the feeling of
this transducer holding is combined with the parasternal log axis view (d).
defined hand position which has to be linked with a defined view.
In echocardiography in adult patients, the echocardiographic in-
vestigation normally starts with the left parasternal approach. It is
obvious that the basic holding of the transducer should be linked
to the long-​axis view of the left ventricle. In consequence, all pos-
sible long-​axis views that can be acquired between the position of
the left parasternal and the apical approach should be linked to
this defined hand-​holding of the transducer. If you change your
basic position of holding the transducer during the scanning pro-
cedure of the same sectional plane, the imagination and associ-
ation of the individual coordinates of the heart within the thorax
will be lost by the investigator, which means that he will become
disoriented or blind during scanning.
It has to be mentioned and emphasized, that scanning is possible
with the right as well as with the left hand. The argument for a cor-
rect scanning technique is always the acquisition of standardized
images with high image quality. Thus, echocardiographic scanning
can be performed as the investigator is, or has been, taught how
to do it. The author of this chapter, however, scans with the right
hand. Thus, the images of how to hold the transducer and adjust the
finger positions are shown for right-​hand scanners.
To get a stable position for the transducer holding, all fingers
are generally lifted and not extended. The pulps of the fourth
and fifth fingers conveniently lie on the small edge of the trans-
ducer without any muscle tension (E Fig. 1.1a). The pulp of
the thumb is con­veniently placed on the notch of the transducer
without any muscle tension (E Fig. 1.1b). This convenient re-
laxed transducer holding has to be conceptionally combined with
 Principles of t r a n sthor aci c echo ca rdi o g r a phy — pr acti c a l aspe c ts 5

Fig. 1.2 Examples of inconveniently holding the transducer. In (a) the fourth and fifth finger are between the transducer and the skin like writing with a
pencil. No stable contact to the skin results in non-​stabilization of the transducer. In (b) the holding is like encompassing a horizontal bar. Thus, rotation of the
transducer is not performed by the hand—​it has to be done by the shoulder and/​or cubital joint. In (c) the thumb is too extended and the pulp of the thumb
is not at the notch causing a blind feeling when moving or rotating the transducer. In addition, the mistake in Fig. 1.2a is also seen. In (d) no finger has contact to
the skin. Thus, every trembling of the hand is bridged to the transducer and consequently to the images on the monitor. It is also not possible to get a basis for a
defined flipping, tilting, and rotation, because the starting position is not stable.

the basic position of the transducer in the parasternal long-​axis
view of the heart (E Fig. 1.1c, d). The loss of the feeling for the
notch and extended or tensed fingers in the starting position
will induce discomfort and restrict the degrees of freedom for
the movement of the transducer. Thus, wrong transducer hold-
ings (E Fig. 1.2a–​d) will lead to disorientation and difficulties
in fine-​tuning for adjusting correct standardized views. An often
observed mistake is not to fix the fourth and fifth finger on the
skin of the patient, leading to an unstable transducer position.
With tilting over the small edge using the transducer holding of
this starting position in the long-​axis view, the mitral valve, for
example, can be moved from the right to the left and vice versa
without losing the long-​axis view.
A clockwise rotation of the transducer from the starting pos-
ition is easy (E Fig. 1.3a), because there is free space to turn
the thumb clockwise by bending backwards the fourth and fifth
fingers (E Fig. 1.3b, c). A 90° rotation is easily possible and thus,
you will get the feeling of rotating exactly 90° clockwise at the
left parasternal window to visualize a correct short-​axis view (E
Fig. 1.3d).
After acquisition of the necessary parasternal short-​axis views
the transducer is rotated counterclockwise back to the cor-
rect long-​axis view. The correct position of the apical window
and the correct apical long-​axis view can be achieved by sliding
down from the parasternal window to the apex without losing
the sectional plane of the long-​axis view (E Fig. 1.4). At the
end of this movement the right hand can support itself against
the thorax with the complete auricular finger (E Figs. 1.5a, b).
Fingers placed between the transducer and the thorax in this pos-
ition will disturb or inhibit the correct documentation of apical
standard views by positioning the transducer too perpendicular
to the body surface inducing a right twisted position of the heart
within the scan sector and/​or foreshortening views. Without
tilting and flipping the correct apical long-​axis view, a clockwise
rotation of exactly 60° can be performed (E Fig. 1.5c) to visu-
alize a correct 2-​chamber view (E Fig. 1.5d).
Combining a defined transducer holding always with the long-​
axis view and getting the stable feeling for this combination are
the prerequisites for target-​controlled scanning and the accurate
assessment of cardiac structures. It is obvious that minimal ma-
nipulations of the transducer position can be easily performed
and stably fixed using the correct scanning technique. Thus, a
correct scanning technique is the prerequisite for images with at
least best possible image quality.
The aim of a sufficient transthoracic, and also transoesophageal,
echocardiographic investigation should be an almost reprodu-
cible standardized documentation, which enables an accurate
diagnostic analysis for correct decision-​making. A standardiza-
tion of the documentation enables a comparison between cur-
rent and previous findings to detect changes, improvements, or
6 CHAPTER 1 C on v ent ional ech o cardio gr a phy — basi c pri n ci pl es

Fig. 1.3 Starting with the correct holding of the transducer for displaying the parasternal long-​axis view (a) the transducer is exactly rotated 90° clockwise (b),
after this movement the pulp of the thumb is at the broad side of the transducer at the top and the third finger is at the broad side of the transducer at the
bottom (b), while the fourth and fifth finger are retracted (c), but they have still contact to the skin. This holding is linked with all parasternal short-​axis views (d).

Fig. 1.4 Photo composition of the transducer holding for the different long-​axis views between the standardized parasternal approach and the standardized
apical approach. On the left side the different holdings at the correct parasternal position, at a position between the parasternal and apical position, as well as at
the correct apical position are shown. In the centre the photomontage of all transducer holdings is shown documenting the plane of all long-​axis views. On the
right side the corresponding views are shown.
 Standardized data ac qu i si ti on i n tr a n sthor aci c echo ca rdi o g r a ph y
Fig. 1.5 With the transducer holding of the parasternal long-​axis view
the hand is slid down to the apical long-​axis view (a). At the position of
the apical long-​axis view the fourth and fifth finger still remain on the skin.
In addition, the complete ulnar area of the fifth finger is placed in position
against the thorax for scanning from the apical approach (a). This transducer
holding is linked with the apical long-​axis view (b). A clockwise rotation of
60° without tilting and flipping has to be done (c) to get the correct apical
2-​chamber view (d).
deterioration of the cardiac state in follow-​ups. Furthermore, the
more standardization is present, the more intra-​and interobserver
variability is reduced. The basis for the correct configuration of an
echocardiographic data acquisition and examination—​including
data acquisition, data documentation, data storage, interpretation,
and reporting of the results—​as well as the correct measurements
and calculations of numerical values in echocardiography is pro-
vided by already published national and international guidelines
and position papers.
Principles of image optimization and
identification of artefacts—​practical
aspects
The echocardiographic images of all modalities are reconstructed
by modern techniques using the physical properties of the ultra-
sound waves interacting with the cardiac and thoracic tissue.
Thus, basic knowledge about the physics of ultrasound is neces-
sary to understand the image reconstruction—​especially with
respect to the possibilities of imaging optimization and the iden-
tification or detection of artefacts.
Ultrasound waves (E Fig. 1.6a–​f ) (E Fig. 1.7a–​d) in echocar-
diography are generated by voltage-​induced vibrations of piezo-
electric crystals of the transducers forming an ultrasound beam
7
which interacts with the tissue. The mapping of cardiac struc-
tures depends on the reflection of the ultrasound waves due to the
travel time between transducer and the respective reflexion zone
and its way back as well as the intensity of reflection. However, re-
flection is only one interaction with the tissue. Refraction, disper-
sion, and attenuation are also contributors to the image quality of
the reconstructed cardiac structures. Thus, acoustic impedances
and the orientation of boundaries in relation to the ultrasound
beams between two different tissues have major impacts on the
receiving ultrasound signals at the transducer for the final image
reconstruction.
With respect to the acoustic window in each patient the
imaging settings have to be altered and optimized to illustrate
the respective cardiac structures in an adequate fashion. The
most important issue to get an optimal image quality is the cor-
rect positioning of the transducer. The most important technical
factors influencing echocardiographic parameters are listed in
E Table 1.1.
Artefacts in echocardiography are created by the interactions of
ultrasound waves with the tissue and by the image reconstruction
algorithms due to beam formation properties. Despite the visual-
ization of artefacts being compatible with the physical laws of re-
flection and refraction, artefacts are not consistent with the usual
assumptions of ultrasound imaging. The common assumptions
of ultrasound imaging are (1) ultrasound travel time is related to
a specific speed (1540m/​s), (2) ultrasound waves are attenuated
uniformly, (3) acoustic reflection of ultrasound waves occurs just
once at a reflector after transmission and (4) the ultrasound trans-
mission is formed by a main thin beam.
Artefacts will be created mainly in the presence of strong
reflectors causing multiple reflections between the reflectors.
Artefacts have to be recognized to avoid misinterpretations.
Sometimes artefacts can be avoided or minimized by chan-
ging the ultrasound settings or by changing the scanning mo-
dalities (E Fig. 1.8a–​c, Fig. 1.9a–​f, Fig. 1.10a–​d, Fig. 1.11a–​d,
Fig. 1.12a–​d). The common artefacts observed in 2D-​, spectral,
and colour Doppler echocardiography are listed and described
in E Table 1.2.
Standardized data acquisition in
transthoracic echocardiography
Left parasternal and apical scanning should normally be per-
formed in left lateral position of the patient.
The transthoracic echocardiographic examination should
start with the correct documentation of the conventional two-​
dimensional left parasternal long-​axis view of the left ventricle
(E Fig. 1.13a–​b). This sectional plane is characterized by the
centre of the mitral valve, the centre of the aortic valve, as well
as by the ‘imaginary’ cardiac apex, which cannot be visualized
from the parasternal approach due to the superposition of the
left lung. The following anatomical structures are visualized by
8 CHAPTER 1 C on v ent ional ech o cardio gr a phy — basi c pri n ci pl es

Fig. 1.6 Impact of ultrasound frequency on 2D-​echocardiography: parasternal long-​a xis view in the same patient using low (a) and high (b)
frequencies—​transoesophageal long-​axis view in the same patient using low (c) and high (d) frequencies (better spatial resolution with higher frequencies,
but less penetration). Impact of ultrasound frequency on Doppler echocardiography: transmittal pulsed-​wave Doppler spectrum with low (e) and high
(f) frequencies (sharper contours with higher frequencies, but less penetration). Impact of gain and low velocity reject on Doppler echocardiography:
transaortic continuous wave Doppler spectrum with low (e) and high (f) gain and adjusted low velocity reject (f) (better contour detection of the velocity
spectrum after adjustment)

the parasternal long-​axis view. In the nearfield of the transducer,
the first myocardial structure is the free right ventricular wall—​
normally parts of the right ventricular outflow tract. The left ven-
tricular cavity in the longitudinal section is surrounded by the
midbasal anteroseptal and posterior regions of the left ventricle.
The mitral valve is sliced in the centre of the valve plane nearly
perpendicularly to the commissure. The aortic valve is also sliced
in the centre of the valve in longitudinal direction. The aortic root
and the proximal part of the ascending aorta are longitudinally
intersected. Behind the aortic root the left atrium is longitudin-
ally intersected. The posterior left ventricular wall is bordered by
the posterior epicardium and the diaphragm. The far field of the
parasternal long-​axis view should include the cross-​section of
the descending aorta behind the left atrium. A standardized left
parasternal long-​axis view can be verified by the following display
of the heart within the sector. The mitral valve has to be centred
in the scanning sector. Then, the ventral boundary of the mid-​
anteroseptal region of the left ventricle on the left side has to be
in line with the ventral boundary of the ascending aorta on the
right side of the sector. Furthermore, the check of the correct lon-
gitudinal parasternal long-​axis view should include the ascending
aorta visualized as a tube and not as an oblique section, the cen-
tral valve separation of the mitral and aortic valves, as well as the
missing of papillary muscles. If papillary muscles are sliced, the
sectional plane is not in the centre of the left cavity, which corres-
ponds to a non-​standardized view. For qualitative assessment of
flow phenomena at the mitral and aortic valves, as well as for the
detection of perimembranous ventricular septal defects, a colour-​
coded 2D cineloop of the left parasternal long-​axis view can be
added to the documentation (E Fig. 1.13c–​d).
With respect to the documentation of the right heart, tilting the
transducer to the sternal regions enables the visualization of the
right ventricular inflow tract with a longitudinal sectional plane
through the tricuspid valve (E Fig. 1.14a–​b). Tilting the long-​
axis view to the lateral regions of the heart enables the visualiza-
tion of the right ventricular outflow tract with the longitudinal
Another random document with
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 Fam. Plethodontidæ.
Plethodon cinereus cinereus (Green). Sugar Grove.
Plethodon cinereus erythronotus (Green). Sugar Grove,
Columbus, and Worthington. In the early part of the year this is the
commonest salamander in the ravines in Franklin County. It is found
generally away from water, under loose debris two or more rods from
the stream.
Plethodon glutinosus (Green). Sugar Grove. This salamander is
found in such localities as were mentioned for P. c. erythronotus.
Gyrinophilus porphyriticus (Green). Sugar Grove.
Spelerpes bilineatus (Green). Sugar Grove. Habits apparently
aquatic.
Spelerpes longicauda (Green). Sugar Grove. This salamander is
abundant in this region where it may be found in May under stones
at the edge of the water together with its eggs; the eggs are attached
to the under side of a hollow stone. Some individuals were found in
May, 1900, away from water.
Spelerpes ruber (Daudin). Fairfield County.
Desmognathus fusca (Rafin). Sugar Grove and Perry Co.
Aquatic in habits.
 Fam. Pleurodelidæ.
Diemictylus viridescens miniatus (Rafin). Sugar Grove.
 Fam. Bufonidæ.
Bufo lentiginosus (Shaw). Columbus and Knox County. This is
the common toad of Central Ohio.
Bufo lentiginosus americanus LeConte. A specimen from the
sand dunes of Cedar Point, Sandusky, Ohio.
 Fam. Hylidæ.
Acris gryllus crepitans Baird. Knox County, Central College and
Columbus. The common cricket-frog of Central Ohio is this
subspecies. The young resemble the species gryllus LeConte in
having the under surface of the thigh reticulated and blotched.
Chorophilus triseriatus (Wied.). Sugar Grove.
Hyla versicolor LeConte. Knox County and Columbus.
Hyla pickeringii Storer. Sugar Grove.
 Fam. Ranidæ.
Rana virescens Kalm. Sugar Grove and Columbus.
Rana palustris LeConte. Sugar Grove.
Rana sylvatica LeConte. Knox County and Sugar Grove.
Rana clamata Daudin. Columbus.
Rana catesbiana Shaw. Columbus.
Summary for Batrachia.—Families 8, Genera 12, Species 25.
 THE PROMETHEA MOTH, CALLOSAMIA
PROMETHEA.

Herbert Osborn.

This beautiful moth is one of the rather common species

belonging to the group of silkmaking Lepidoptera. The moths appear
in May or June. The female is light rusty brown and drab with a
darker area across the middle of the wings, while the males are much
darker, nearly black, and differ further from the females in the shape
of the wings and markings as shown in the figures.

Fig. 1. Callosamia promethea, female. (H. O. ad. nat. 1880.)

 The eggs are laid in early summer almost immediately after
pairing, and hatch in course of a few days, the larvae growing
through the summer. The cocoons are hung to twigs of trees by a
silken cord, and quite often a leaf is utilized as the outer covering
within which the elongate oval cocoon is built. In any case the cocoon
bears resemblance to a withered curled leaf hanging by its petiole. In
this manner cocoons hang upon the trees through the winter.
They are found most commonly on wild cherry, this being
apparently the favorite food plant of the larva. They feed however on
a large number of common trees and shrubs.

Fig. 2. Callosamia promethea, male. (H. O. ad. nat. 1880.)

The figures of the moth, male and female, were drawn twenty
one years ago, and having now come of age they may perhaps be
trusted to make their first public appearance.
 MEETING OF THE BIOLOGICAL CLUB.

The Biological Club met in Zoological lecture room on the

evening of April 1, 1901. Professor Osborn presided.
Professor Schaffner reviewed a paper entitled Zur Kenntniss der
Zelltheilung bei Myriopoden, published in Archiv fur
Mikroskopische Anatomie.
Dr. Morrey spoke on the subject, “Two years in Europe as a
Student.” Most of the time was spent at the University of Vienna,
although the University at Zurich and the Pasteur Institute at Paris
were each attended for a short term.
The University of Vienna ranks among the first in the
advantages offered to medical students. The hospitals of the city are
noteworthy on account of the large number of cases and the great
variety of diseases treated. The numerous holidays observed in
Vienna seriously interrupt college work. Hardly a week passes in
which there is not one or more holidays on which work is wholly
suspended.
The speaker placed on the exhibition table a fine series of
photographs procured during his stay abroad. These furnished a
treat for those present after the regular program was completed.

Jas. S. Hine, Secretary.

 NEWS AND NOTES.

The Summer Field Meeting of the Ohio State Academy of

Science will be held at Wooster, Ohio, on Friday and Saturday, May
31 and June 1, 1901, under the auspices of the University of Wooster,
the Ohio Experiment Station and the Wooster Field Naturalist’s
Club. The plan includes Friday about the small lakes southwest of
Wooster, and an evening meeting in Wooster; Saturday morning at
the Experiment Station, to be followed by an excursion to North
Lawrence with its mines and Fox Lake with its tamarack bog.
Prof. Charles S. Prosser in an article in the Am. Jour. of Sci.
11:191–199, 1901, discusses the names applied to the formations of
the Ohio Coal measures. The following names are proposed.

Present Names. Proposed Names.

Upper Barren Coal Measures Dunkard formation
Upper Productive Coal Measures Monongahela formation
Lower Barren Coal Measures Conemaugh formation
Lower Productive Coal Measures Allegheny formation

The Philadelphia Fleabane (Erigeron philadelphicus L.) is one of

our interesting spring plants and will repay careful study. The leaves
of the stem in most individuals have a decided polarity and for the
most part are twisted so as to stand in a single plane. In this respect
the plant is as striking as any of the so-called compass plants,
although the plane in which the leaves lie may be in any direction.
Another interesting adaptation is the drooping of the top of the
young plant. The entire inflorescence nods at first and finally the
individual heads, but one by one these assume the upright position
as the flowers begin to open.
 J. H. S.

Winter Adaptation of Opuntia.—The Ohio species of cactus,

Opuntia humifusa Raf., has an interesting habit which seems to be a
protective measure against cold. At the approach of Winter the
flattened stems lose their upright position and press themselves
closely to the surface of the ground.
The stems lose considerable of their moisture at the same time,
becoming wrinkled but not at all flaccid. By the end of April they are
again upright and distended.

F. J. T.
 Ohio State University
Six distinct and independent Colleges, each with a Dean and
Faculty of its own.

THIRTY SEVEN DEPARTMENTS. THIRTY DISTINCT

COURSES.

Agriculture, Arts, Law, Engineering, Pharmacy,

Veterinary Medicine.

Superior facilities for education in Applied Science. Short or

special courses for mature students not candidates for degrees.
One hundred and twenty one instructors. Over thirteen hundred
students.
FINEST GYMNASIUM IN THE WEST.

For further information address the President,

Dr. W. O. Thompson, State University, Columbus.

Ohio Forest Trees Identified by Leaves and Fruit.

By W. A. Kellerman, Ph. D., Ohio State University.
A neat pamphlet for every one who wishes to learn our native
forest trees. Keys simple. Description plain. Can learn the names of
the trees easily.

Price reduced from 25 cents to 10 cents.

Also, The Fourth State Catalogue of Ohio Plants.

Bound copies at cost of binding, namely 20 cents.

Gives list of scientific and common names; distribution by

counties.
 Teachers and others will also be interested in Prof. Kellerman’s
Phyto-theca or Herbarium Portfolio, Practical Studies in Elementary
Botany, Elementary Botany with Spring Flora, all published by
Eldredge & Bro., Philadelphia, to whom apply.
For information or copies of Forest Trees and Catalogue or
names of plant specimens of your region address

W. A. Kellerman, Columbus, Ohio

American Entomological Co.

1040 DE KALB AVENUE, BROOKLYN, N. Y.

Lepidoptera Price List No. 2.—Price 5 cents Refunded to Buyers

Issued November 15th 1900.

Dealers of all kinds of ... Entomological Supplies

Manufacturers of the Original and Celebrated ... SCHMITT INSECT

BOXES

Builders of INSECT CABINETS, ETC.

The Twentieth Century Text Books of Biology.

PLANT RELATIONS, 12mo, cloth $1.10

PLANT STRUCTURES, 12mo, cloth 1.20
PLANT STUDIES, 12mo, cloth 1.20
PLANTS, 12mo, cloth 1.80
ANALYTICAL KEY TO PLANTS, 12mo, flexible cloth .75

All by JOHN MERLE COULTER, A. M., Ph. D., Head of Dept. of

Botany, University of Chicago.
They are already the preferred texts,
and the reasons will be apparent on
examination.
 ANIMAL LIFE: A First Book of Zoology.
By DAVID S. JORDAN, M. S., M. D., Ph. D., LL. D., President of
the Leland Stanford Junior University, and VERNON L.
KELLOGG, M. S., Professor in Leland Stanford Junior
University. 12mo. Cloth, $1.20. Now ready.
Not a book for learning the classification, anatomy, and
nomenclature of animals, but to show how animals reached their
present development, the effects of environment, their place in
Nature, their relations to one another and to the human race.
Designed for one-half year’s work in high schools. Send for sample
pages.

ANIMAL FORMS: A Second Book of Zoology.

By DAVID S. JORDAN. M. S., M. D., Ph. D., LL. D., and HAROLD
HEATH, Ph. D., Professor in Leland Stanford Junior University.
Ready in February, 1901.
D. APPLETON AND COMPANY, Publishers, New York,
Chicago, London.

Recent Scientific Works

In Astronomy, Dr. Simon Newcomb’s new book, published
October, 1900; in Physics, the Johns Hopkins text of
Professors Rowland and Ames; also in Physics for second and
third year high school work, the text of Dr. Hoadley, of
Swarthmore; in Physiology, the text by Drs. Macy and
Norris, based on the Nervous System; also the High School
Physiology indorsed by the W. C. T. U., written by Drs.
Hewes, of Harvard University; in Geology, the Revised
“Compend” of Dr. Le Conte, and the two standard works of
Dana,—The Manual for University Work, and the New
Text Book, revision and rewriting of Dr. Rice, for fourth
year high school work; in Chemistry, the approved Storer
and Lindsay, recommended for secondary schools by the
leading colleges; in Zoology, the Laboratory Manual of
Dr. Needham, of Cornell; and the series “Scientific
Memoirs” edited by Dr. Ames, of Johns Hopkins. Nine
volumes ready.
The publishers cordially invite correspondence.

AMERICAN BOOK COMPANY, Cincinnati

 TRANSCRIBER’S NOTES
1. Silently corrected obvious typographical errors and
variations in spelling.
2. Retained archaic, non-standard, and uncertain spellings
as printed.
*** END OF THE PROJECT GUTENBERG EBOOK THE OHIO
NATURALIST, VOL. I, NO. 7, MAY, 1901 ***

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