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Echocardiography for

Primary Care Amr E Abbas, MD, FACC, FASE, FSVM, RPVI

Interventional Cardiology, Northpointe Heart Center

Co-Director Echocardiography, William Beaumont Hospital

Associate Professor of Medicine, OUWB School of Medicine

Topics of Discussion

Advantages of Echocardiography

Techniques of Echocardiography

Modalities of Echocardiography

When to Order an Echo:

Anatomy versus physiology

Future of echocardiography

Advantages

Readily available

Affordable

Provides anatomy and physiology

Mobility

Does not use X-rays or nephrotoxic dye

Usually no post processing required

Techniques

Transthoracic

Transesophageal

Intracardiac

Fetal

Transthoracic Echocardiography

Fischer et al. J Cardio Vasc Anest 2009 531-543

Transesophageal Echocardiography

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IAS Mechanical

Vs. Phased array

ASD Mechanical

Vs. Phased array

Amplatzer Mechanical

Vs. Phased array

Intracardiac Echocardiography Fetal Echocardiography

Modalities

M Mode

2 D

Color Doppler

Spectral Doppler

3 and 4 D

Tissue Doppler

Contrast echocardiography

Stress Echocardiography

Echocardiography

Tomography

Echocardiography

M-Mode Echocardiography

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Principles of M-Mode

2-D Echocardiography

Normal Cardiac Motion

Systole/Diastole

Cardiac Mechanics

End Diastolic volume (EDV) = Volume of heart at end diastole 120

ml (65-240 ml)

End Systolic Volume (ESV) = Volume of heart at end systole 50 ml

(16-143 ml)

Stroke volume (SV) = EDV – ESV 70 ml (55-100 ml)

Ejection Fraction (EF) = SV/EDV ( > 55%)

Cardiac output (CO)= SV x HR 5 l/min (4.8-6.4 l/min)

Blood pressure (BP) = CO x systemic vascular resistance (SVR)

Hemodynamic Calculations

2-D Method

HR: 60 BPM

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Hemodynamic Calculations

Stroke Volume:

EDV – ESV = 66.8 – 22 = 44.8 ml

Ejection Fraction:

EDV – ESV/EDV = 67%

Cardiac Output:

SV x HR = 2.68 l/min

Contrast Echocardiography

Constrast

HR 125

Stress Echocardiography

Exercise Exercise

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Exercise

Doppler Echocardiography

Doppler Velocity Wave Form

Time

Ve

loc

ity

Instantaneous velocity at tx

tx

Flow cm3/sec = Velocity cm/sec x Area cm2

Doppler Velocity Wave Form Time

Ve

loc

ity

TVI cm Linear distance

Volume cm3 = Area cm2 x Distance cm

Systole Diastole

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3 D Echocardiography

Complex Relationship of the Valves

True Anatomy: Aortic Valve, 3D TEE

Aortic Valve

True Anatomy: Mitral Valve, 3D TEE

Mitral Valve

True Anatomy: Appendage, 3D True Anatomy: Atrial Septum, 3D

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When is it appropriate to Order an

Echocardiogram

Symptoms/Signs

Chest Pain

Shortness of Breath

Arrhythmias

Syncope

Embolic event

Fever and bacteremia

Murmurs

Stress

Low, intermediate, and high risk for Ischemia unless able to exercise with interpretable EKG

Diseases

Diseases

Valve disease

Aortic disease

Pulmonary hypertension

Hypertension

STEMI/UA

Trauma

TEE:

Endocarditis

Embolic event

Valve disease

Appropriateness Criteria

Anatomy Versus Physiology

Anatomy

Regional and global wall motion

Cardiac masses

Pericardial effusion

Chamber dimension

Wall thickness

Physiology

Diastolic function

Pericardial Effusion/Tamponade/Constriction

Valve Heart disease

Stenosis

Regurgitation

Ischemia: Stress Test

Cardiac Structure

Anatomy

LV

LV

RV

LA RA

RV

LA

AV AO

AML

PML

Systolic Dysfunction Changes with Hypertension

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Apical Clot Apical Clot

Mitral Valve Endocarditis Prosthetic Mitral Valve

PFO with a Positive Bubble Study PFO with a Clot

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Identifying Pathology : Large ASD, 3D

TEE ASD Amplatzer Device

Cardiac Physiology

Hemodynamics Cardiac Hemodynamics

Systole and Diastole

IVC Systole IVR Early

Filling Diastasis

Atrial

Contraction

Cardiac Catheterization

Right and Left Heart

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Hemodynamic Calculations

Doppler Method

Systole Diastole

STROKE VOLUME

Stroke

volume

Flow = Area x Velocity

CONTINUITY LAW

75 mL

75 mL

Hemodynamic Calculations

Doppler Method LVOT

d=2

TVI=23

SV = 72cc

Mitral

d=2.9

TVI=1

2 SV = 79cc

Tricuspid

d=3.4

TVI=8 SV = 72cc

Hemodynamic Calculations

Normal and Low SV

Normal EF Low EF

Valve Hemodynamics

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Valves: Normal

Mitral Aortic

Valves: Normal

Mitral Aortic

Valves: Stenosis

Mitral Aortic

Q

R V2 V1

A1 A2 A3

V3

V 1,2&3 Velocity

A 1&2 Area

Q Flow

R Resistance

P1,2&3 Pressure

D Distance

P2 P1

D

P3

Vascular Mechanics: Stenosis

V3

R

Valves: Stenosis

Aortic Mitral

Δ pressure = 4V2

Regurgitation

Mitral Aortic

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Regurgitation

Aortic Mitral

CONTINUITY LAW

75 mL

75 mL

Flow 1 = Area 1 x Velocity 1 Flow 2 = Area 2 x Velocity 2

Flow 1 = Flow 2 and Area 1 x velocity 1 = Area 2 x Velocity 2

120 cc

70 cc 50 cc

Regurgitant volume = 120-70 = 50 cc

Regurgitant fraction = 50/120 = 42%

Systole Diastole

Application to Valve Disease Mitral Regurgitation

Pericardial Hemodynamics

Tamponade Tamponade

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Amyloid Restrictive Disease Constriction

Pulsus Paradoxus Kussmaul’s Respiration

Future of Echocardiography

Hand held

Tissue analysis

Therapeutic Echocardiography

Studies of cardiac motion

Dual Doppler

Hand Held Echocardiography

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Tissue Strain

Focus: The Role of Multimodality Imaging

in Interventional Planning

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Rates!

Register Online: http://heart.beaumont.edu/classes-and-events

Conclusions

Echocardiography provides

Readily available,

Relatively inexpensive,

Non-invasive

Anatomical and physiological evaluation of the

heart.

Appropriate criteria exist for indications