2D real time

M-mode

Spectral Doppler

CW

-safe

-most freq used in dx of heart dz

-exceeds x-ray and ECG

-gold standard

1793- Bats

1845- Christian Doppler (Doppler Effect)

1880- Curie bros- piezoelectricity

WWII- Sonar

1954- Hertz and Elder-motion display A& B mode

M-mode followed

early 1970s 2D clinical

late 1970s- Spectral doppler

1980- CW doppler

-assess cardiac morph, path, and functuion

-high operator dependent

-info and data should be accurate and reproducible

-sonographer caple and competent

• Accuracy
• achieved thru education and knowledge
• id and recognize pitfalls and limits of technique
• Reproducibility
• attained thru standard views and technique
• Standardization
• image orientationis crucial in display anatomy of heart
• improves accuracy and reproducibility

• tranducer selection
• depth
• zoom
• focus
• gain
• TGC time gain compensation
• dynamic range
• pre and post processing
• B-color

-should be highest freq that allows for adq penetration to structure or ROI (region of interest)

-increased freq, decreased penetration, increased resolution

-best resolution w a high frq trans

-best depth penetration occurs w low freq trans

-adjusts vertical field of view of image

-affects frame rate

--deeper field of view the greater the time required for signal to return to transducer

-slower frame rate

--shallower field of view, less time required for signals to return

-higher frame rate

--in order to maintain FR, smallest field of view that allows ROI should b used

-focal zone indicates region of image where u/s beam is narrowest

--resolution is greatest

---important to reposition focal zone when doing 2D measurements and looking at ROI such as endocardial define and valves

-allows adjustment of displayed amplitude of all received signals

--affects brightness

-Optimal:

-settings should provide enough signal amplification to produce desired image w/o dropout or "blooming"

TGC

time gain compensation

TGC or DGC adjust amplitude or gain of returning echoes along length of beam or at specific image depth

----U/S is attenuated----

-insures signals of similar magnitude r displayed at same amplification

TGC used in conjunction w gain control to produce desired image

-represents ratio of max to min signal level and expressed in dB

-increasing dynamic range increases amt of gray scale displayed so weaker signals are included and image is softened

-decreasing results in high quality contrast images so weaker signals are eliminated, noise is reduced and strong echoes enhanced

-dynamic range should be increased when images good quality and decreased when image quality is poor

preprocessing

postprocessing

-pre: manipulation of data as it is

-post:  manipulation of data after its stored

-smoothing of image that is achieved by averaging several frames

-reduces image noise and improves image quality

-disadvantage: inferior temporal resolution

-avg of several frames of moving structures results in blurring of real time image

-minimal persistance is used in assessment of heart

-brightness color

-assists in improving contrast resolution

-uses color instead of gray scale

human eyes only appreciate limited # shades og gray, but able to distinguish greater # of colors

-changing color of image may allow enhanced appreciation of soft tissue structures

-special windows required to imGE HEART

- Cuz heart is mostly covered by bony structures such as ribs, sternum and lung tissu

--dense materials such as bone: totally absorbs sound waves

--air filled: totally reflect

-echo windows are areas in which heart does not lie directly beneath bone and lung surfaces

-parasternal

-apical

-subcostal

-suprasternal notch

-occas right parasternal

-sagittal, transverse and coronal not generally used

-heart lies in oblique position

-orientation and position of heart is variable

-long axis plane

-short axis plane

-4 chamber plane

-plane perpendicular to dorsal and ventral surface of body and parallel to long axis of heart

-provides info bout aorta, LA, LV, interventricular septum and posterior wall of LV

-plane perpendicular to dorsal and ventral surface of body and is perpendicular to long axis plane

-various levels can examine apex, mid level, base, and great arteries

-runs parallel to dorsal and ventral surface of body and transects heart from its apex to its base encompassing all 4 chambers

-heart is divided into 4 chambers by interventricular and interatrial septa in long plane and by atriovent valves in transverse plane

-long axis

-short axis

-4 chamber

-5 chamber

-long axis

-2 chamber

-4 chamber

-short axis

-long axis

-short axis

-LV

-LA

-aortic valve/prox asc aorta

-mitral valve

-RV

-RVIT--RV,RA,TV

-RVOT--PV, PA

-pulmonary artery bifurcation

-aorta and LA

-LVOT

-LV at MV level

-LV at pap muscle level

-LV at apex

-apical 4 chambers= 4 chambers

-apical 5 chambers= 4 chambers aND AORTA

-apical long axis= LV and aorta

-apical 2 chamber= LV and  LA

-subcostal 4 chamber= 4 chambers

-subcostal short axis= all levels as PSAX and IVC and abd aorta

-suprasternal long axis= aortic arch

-suprasternal short axis= aortic arch

-movement:

-tilting

- angulation

-rotation

-image orientation

3 major movements

-tilting

-angling

-rotating

-footprint stays in same place but tail of transducer is altered

-tilting changes scan plane

-superior: tilting tail towards patints feet

-inferior: tilting tail towards patients head

-anterior: tilting image toward patients front

-posterior: tilting image plane toward ptients back

-side to side movementof transducer from a fixed point on chest wall

-footprint remains in same position on ches t\\t wall

-brings strucutres of interest at the side of the image plane into center of image

- medial: pt trans toward midline

-lateral: pt trans toward side of patient or away from midline

-pivoting or twisting of transducer from a fixed position on chest wall

-clockwise

-counterclockwise

thoracic cavity, left of mediastinum

-fibrous-outer layer

-serous- inner layer, made of 2 layers

--parietal

--visceral (same as epicardium)

-fluid-filled space is between parietal and visceral

--serous fluid- straw colored

--approx 10-50 cc

lubricates pericardial surfaces

----epicardium:

-outer layer

-same as visceral layer of pericardium

----myocardium:

-center layer

-striated muscle and myofibrilis

----endocardium:

-inner lining of heart, valves, chordae, and pap muscles

-thin layer of endothelium and connective tissue

-right border:

formed by RA

-inferior border:

formed by RV and apical part of LV

-left border:

formed by LV

-apex:

formed by LV

corresponds to apex of heart

-superior border:

formed by roots of great vessels

-atrioventricular sulci:

between atria and vent

-interventricular sulci:

between vent

-interatrial sulcus:

delineates the atria

-grooves and sulci are composed of epicardial fat, coronary arteries and veins

head/neck:

-int jug vein

-cheif veins that drain head and neck

-joins subclavian vein

upper ext:

-veins in arms join aux vein in armpit

--basilic

--cephalic

--brachial

upper ext:

-aux vein changes to subclavian vein

-subclavian vein receives ext jug and then joins int jug

forms the brachiocephalic vein

chest wall:

-azygos and hemiazygos veins drain lwer thoracic wall

-enter lower most portion of svc before entering RA

-receives systemic venous drainage from lower limbs, abd, and portal system

-ext iliac vein joins int iliac to form common iliac vein

-when femoral vein enters abd, name changes to ext iliac

portal system:

-hepatic veins receive blood from the liver as well digestive tract from portal vein

-prior to entering thr RA the ivc received blood from the hepatic veins

-oxygenated blood from lungs is returned to left side of heart by pulm veins

-superior and inferior pulm veins pass each lung to the LA

-superior pulm veins collect blood from RU and middle lobes and LU lobes

-inferior pulm veins collect blood from the RL and LL lobes

-most of myocardium is drained via venous tributaries that connect to great cardiac vein

-great cardiac vein empties into coronary sinus

-lies on R surface of heart

-2 parts:

-posterior, smooth walled region

-anterior trabecular region

-scv enters posterior corner

-ivc and coronary sinus enters lower posterior corner

-orifice of ivc is guarded by eustachian valve

helps direct blood from RA to LA during fetal circulation

-eustachian valve large and perforatededfoforms a lace like structure called the chiari network

-RAA is off anterior RA

-located on left side of heart adjacent to RA

-receives pulm venous blood

-post LA

--smooth walled, inflow chamber

--pilm veins

-ant LA

--trabecular and cont w the LAA

-located between RA and RV

-three leaflets

--septal

--posterior

--anterior

-located between the LA and LV

-sometimes called the bicuspid

- 2 leaflets:

--anterior

--posterior

-located between LV and aorta

-3 cusps:

Right-rca here

Left- LCA here

non-coronary

-located between RV and pulm artery

-3 cusps:

--ant

--r

--l

4 sections:

-ascending aorta

-aortic arch

-descending aorta

-abd aorta

-ascending aorta

--begins at aortic annulus

--lies within pericardial sac

--runs to right of pulm trunk

--areas referred to:

aortic annulus

sinus of valsalva

sinotubular junction

tubular aorta

-aortic arch:

-travels over right plm artery and left bronchus

3 branches:

innominate

left common carotid

left subclavian

-ligamentum artiosum-fibrotic remnant of fetal circulation

-descending aorta:

--beyond ligamentum arteriosum to level of diaphragm

--adjacent to left surface of vert column, esophagus, and LA

--intercostal arteries arise from descending aorta

abd aorta:

-begins at level of 12th thoracic vertebra after passing diaphragm

-adjacent to ivc

-courses down to level of umbilicus or 4th lumbar vertebra

-branches into R and L common iliac

-phrenic, celiac, superior and inferior mesenteric arteries, renal, and lumbar arteries arise from abd aorta

-delivers deoxygenated blood from RV to lungs

-pulm trunk originates from RV at level of the PV

-MPA travels to left of aorta and bifurcTES INTO RIGHT AND LEFT PULM ARTERIES

-R pulm art

-travels behind aorta and scv to the righr

L pulm artery:

travels in front of descending aorta and to the left

plax

-patient in left lat decub

-trans in 3rd or 4th intercostal space along left sternal border

-thumb on groove

900 position

-structures appear from top to bottom as they are encountered by beam

RV inflow view:

-pt in left lat decub

angle trans so beam is directed inferior and sl medial from plax view

RV outflow tract view:

-pt in left lateral decub

-angle trans beam is directed superior and medial from plax view

PSAX:

-pt in left lat decub

-rotate trans clockwise 90 degrees from plax

12oo position

cross sectional view

-4 levels:

-aortic

-mitral

-pap

-apical

PSAX aortic level

most superior

structures:

-rvot

-ao and all 3 av cusps

pv/mpa

la

ias

ra

rv

psax mv level:

-angle inferior from psax av level

-fish mouth view

structures:

-portion of rv and rv  free wall

-lv cavity and lv wall segments

-ant and post mv leaflets

psax pap level:

-angle inferior from psax mv level

-maintain circular appearance

structures:

-rv and rv free wall

-lv cavity and lv wall segments

-posteromedial and anterolateral pap muscles

psax apical level

-most inferior of all psax level

structures:

-lv cavity and lv wall segments

-may or may not see portion of rv

parasternal window

plax

pt in left lat decub position

trans in 3rd or 4th intercostal space

thumb on groove 900 position

structures appear fom top to bottom as encountered by beam

-anterior wall of r vent

-rv cavity

-prox ascending aortic root

appears as 2 relatively thin parallel lines that move ant during systole and post in diastole

-mitral valve leaflets and their subvalvular apparatus

-amvl- appears longer and larger than smaller pmvl

--both leaflets should appear thin, produce uniform echoes and b unrestricted

--normal sinus rhythm there are 3 distinct patterns of mv motion corresponding to 3 phases that occur during diastole

-posterolateral pap muscle:

cone shaped protrusion arising from endocardial surface of the lv myocardium

-chordae tendinae:

taut string like fibers spanning between pap muscles and mitral leaflets

-LA:

lies posrterior to aortic root

cavity should be free of echoes

-basal and mid portions of interventricular septum and the posterior wall of LV:

-should be seen to produce uniform echoes

-thickness should be symmetric measurong no more than 1.1 cm during diastole

-during systole as LV contracts, the ivs thickens and moves posteriorly or inward into lv cavity

-during diastole the septum moves anteriorly or outward

posterior wall of lv moves in the opposite in the opposite direction to ivs

-during systole the posterior wall moves anteriorly or upward

-during diastole this wall moves posteriorly or outward

-between ivs and the post wall

-should b free of echoes

-cardiac apex is normally not seen in lax view