standard echo examination - european society of...
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Standard echo examination
Prof. Dr. Alan FraserCardiff University
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Before starting the examination ..
• check the patient’s details
• understand the clinical questions
• record patient’s height and weight
• record / document arterial blood pressure
• allocate sufficient time (30-60 minutes)
• use good & well maintained echo machine
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A 12-year old girl with a murmur
Echocardiogram performed 16
months previously
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Sensitivity
0
0,2
0,4
0,6
0,8
1
1 11 21 31 41 51 61
Elements
Vo
lts p
-p
Sensitivity
0
0,2
0,4
0,6
0,8
1
1 11 21 31 41 51 61
Elements
Vo
lts p
-p
Sonora FirstCall Test
Performance of a normally functioning transducer
Testing of the transducer used in the
clinical study
Performance of ultrasonic transducersSensitivity of individual elements
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Transducer defect Number Frequency % 95% CI %
Delamination 179 26.5 23.5 - 29.8Break in the cable 57 8.4 6.3 - 10.5Short circuit 23 3.4 2.0 - 4.8Weak elements 6 0.9 0.2 - 1.6Dead elements 4 0.6 0 - 1.2Total 269 39.8 ─
Mattias Mårtensson, Eur J Echocardiogr 2009;10:389-94
Testing of ultrasonic transducers in Sweden676 transducers in routine clinical use in 32 hospitals
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How to set up the patient
• steep left lateral (decubitus) position
• unrestricted access to the apex
• patient comfortable
• good-quality ECG (large R wave amplitude)
• operator comfortable (straight back)
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How to set up the patient
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Use a systematic approach
• Structure / morphology2D, (3D)M-mode, anatomical M-
mode• Function / flow
M-mode, colour M-modeColour flow mappingMyocardial velocity imaging
• HaemodynamicsContinuous wavePulsed Doppler with sound
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Use anatomical M-mode for good alignment
Don’t use Teichholz
!
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Colour M mode: flow propagation velocity
20.9 cm/s
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CW of VSD
Colour M-Mode(MQ)
High spatial &
temporal
resolution for
resolving flow
events
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Use every view, every time
• Parasternal long axis- RV inflow & outflow
• Parasternal short axis- AV, basal, mid, apical LV ....
• Apical views- A4C, A2C, APLAX ..
• Subcostal views• Suprasternal views
and SCAN the whole structure !
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Try to avoid apical foreshortening
Ratio 1.6 2.1
Sphericity 62 % 47 %
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Estimation of right atrial pressure
Change in diameter of inferior caval vein
Inspiration Sniff
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Sensitivity
%
Specificity
%
RA vol min >30 cm3 44 90
RAEF <40% 56 87
IVC collapse <50% 72 76
Tricuspid E/A ratio <1.1 66 92
Hepatic vein SFF <55% 86 90
Nagueh SF et al, Circulation 1996; 93: 1160-9
Non-invasive estimation of right atrial pressure
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Diagnosis of tricuspid regurgitation
Color Doppler CW Doppler Hepatic Vein Flow
Mild
TR
Severe
TR
S
SD
D
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Suprasternal imaging of aorta34yr ♂, bicuspid aortic valve
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Recording and reporting
• Store digital images and loops- including multiple beats
• Always review the study when reporting• Measure, don’t guess ..
- ejection fraction and LV volumes• Index for body surface area• Compare with age-derived normal values• Answer the clinical question ..
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+ 60° + 120°
ASE 16 segment model – now 17
EJE 2006; 7: 79
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Echocardiographic segmentation
RV
LV
ML
MAMAS
MS
MPMI
A4C
APLAXA2C
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The normal heart is a piston pump ..
Stig Lundbäck and Lars-Åke Brodin
.. so analyse & report long-axis function,
and not just global & radial function
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M aged 42 y, AVR for dissection with AR
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Medial mitral annulus
Lateral mitral annulus
Tricuspid annulus
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Don’t make diastole too simple
– remember normal patterns of ageing– assess both relaxation & stiffness/filling
Male aged 68
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Relaxation
Compliance
E/A ratio, E deceleration timeIsovolumic relaxation timeFlow propagation velocityMyocardial Ve, Se, SRe
Short duration A waveIncreased PV reversed flowE/e’ ratio (E/a)
Left atrial volume
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A 24-year old man referred with a “chest infection”
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Be critical and avoid fashion ...
Normal cardiac morphogenesis
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Apical anterior
Apical lateral
Apical inferior
Normal regional variations in trabeculations
Kohli SK et al, Eur Heart J 2008; 29: 89-95
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Improving quality & clinical outcomes
• Base practice on evidence & clinical impact
• Implement quality-improvement programmes
• Use echo with other imaging modalities
Not just better pictures
but more information about function