Ebook ASE''s Comprehensive echocardiography textbook (2nd edition): Part 1

(BQ) Part 1 book ASE''s Comprehensive echocardiography textbook presents the following contents: Physics and instrumentation, transthoracic echocardiography, intracardiac echocardiography, intravascular ultrasound, hand held echocardiography, transesophageal echocardiography, contrast echocardiography,...

Elsevier | ExpertConsult.com

Enhanced eBooks for medical professionals

Compatible with PC, Mac®, most mobile devices, and eReaders, Expert Consult

allows you to browse, search, and interact with this title – online and offl ine

Redeem your PIN at expertconsult.com today!

PIN REDEMPTION INSTRUCTIONS

Start using these innovative features today:

• Seamless, real-time integration between devices

• Straightforward navigation and search

• Notes and highlights sharing with other users

through social media

• Enhanced images with annotations, labels, and

hot spots for zooming on specifi c details *

• Live streaming video and animations *

• Self-assessment tools such as questions

embedded within the text and multiple-format

quizzes *

* some features vary by title

1. Login or Sign Up at ExpertConsult.com

2. Scratch off your PIN code below

3. Enter PIN into the “Redeem a Book Code” box

4. Click “Redeem”

5. Go to “My Library”

Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on ExpertConsult.com Access to the eBook is limited to the fi rst individual who redeems the PIN, located

on the inside cover of this book, at ExpertConsult.com and may not be transferred to another party by resale, lending, or other means.

Call: within the US and Canada: 800-401-9962;

outside the US and Canada: +1-314-447-8200 For technical assistance: Email: online.help@elsevier.com;

ASE ’s Comprehensive Echocardiography

ASE ’s Comprehensive Echocardiography

ROBERTO M LANG, MD, FASE, FACC, FAHA, FESC, FRCP

Professor of Medicine

Director, Noninvasive Cardiac Imaging Laboratories

University of Chicago Medical Center

Chicago, Illinois

STEVEN A GOLDSTEIN, MD, FACC

Director, Noninvasive Cardiology Lab

Washington Hospital Center

Washington, District of Columbia

ITZHAK KRONZON, MD, FASE, FACC, FAHA, FESC, FACP

Professor of Medicine

Department of Cardiology

Hofstra University School of Medicine, and LIJ/North Shore Lenox Hill Hospital,New York, New York

BIJOY K KHANDHERIA, MD, FASE, FACC, FESC, FACP

Director, Echocardiography Services

Aurora Health Care

Aurora Medical Group

Aurora St Luke Medical Center

Director, Echocardiography Center for Research and Innovation

Aurora Research Institute

Co-Director, Aurora Center for Cardio-Oncology

Clinical Adjunct Professor of Medicine

University of Wisconsin School of Medicine

Milwaukee, Wisconsin

VICTOR MOR-AVI, PhD, FASE

Professor, Director of Cardiac Imaging Research

University of Chicago Medical Center

Chicago, Illinois

Philadelphia, PA 19103-2899

ASE’S COMPREHENSIVE ECHOCARDIOGRAPHY,

Copyright © 2016, 2011 by Saunders, an imprint of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered,

to verify the recommended dose or formula, the method and duration of administration, and contraindications.

It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Preceded by Dynamic echocardiography / American Society of Echocardiography; [edited by]

Roberto M Lang [et al.] c2011.

Includes bibliographical references and index.

ISBN 978-0-323-26011-4 (hardcover : alk paper)

I Lang, Roberto M., editor II Goldstein, Steven A., M.D., editor III Kronzon, Itzhak, editor IV Khandheria, Bijoy, editor V Mor-Avi, Victor, editor VI American Society of Echocardiography, issuing body VII Title VIII Title: American Society of Echocardiography comprehensive echocardiography IX Title:

Content Development Manager: Margaret Nelson

Publishing Services Manager: Patricia Tannian

Project Manager: Kate Mannix

Design Direction: Brian Salisbury

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Assistant Professor of Medicine

Research Associate of Cardiovascular

Cardiac Diagnostic Clinic

Duke University Medical Center

Durham, North Carolina

Mount Sinai Health Network

New York, New York

Yoram Agmon, MD

Director, Echocardiography Laboratory andHeart Valves Clinic

Department of CardiologyRambam Health Care Campus;

Associate Clinical ProfessorBruce Rappaport Faculty of MedicineTechnion–Israel Institute of TechnologyHaifa, Israel

Mohamed Ahmed, MD

Department of MedicineDivision of Cardiovascular MedicineUniversity of MassachusettsMedical School

UmassMemorial HealthcareWorcester, Massachusetts

Carlos Alviar, MD

Cardiology FellowLeon H Charney Division of CardiologyNew York University Langone MedicalCenter

New York, New York

Bonita Anderson, DMU (Cardiac),

M Appl Sc (Med Ultrasound)

Senior LecturerMedical Radiation SciencesQueensland University of TechnologyBrisbane, Queensland, Australia

Edgar Argulian, MD, MPH

Mount Sinai St Luke’s HospitalMount Sinai Health SystemNew York, New York

Federico M Asch, MD, FACC, FASE

Associate DirectorCardiovascular Core LaboratoriesMedStar Health Research Institute atWashington Hospital Center;

Assistant Professor of MedicineGeorgetown UniversityWashington, DC

Gerard P Aurigemma, MD, FASE

Division of Cardiovascular MedicineDepartment of Medicine

University of Massachusetts MedicalSchool

UmassMemorial HealthcareWorcester, Massachusetts

Kelly Axsom, MD

FellowCardiovascular DiseasesLeon H Charney Division of CardiologyNew York University Langone MedicalCenter

New York, New York

Luigi P Badano, MD, PhD, FESC, FACC

ProfessorDepartment of Cardiac, Thoracic, andVascular Sciences

University of PaduaPadua, Italy

Revathi Balakrishnan, MD

Cardiology FellowLeon H Charney Division of CardiologyNew York University Langone MedicalCenter

New York, New York

Sourin Banerji, MD

Heart Failure and Transplant FellowUniversity of Pennsylvania PerelmanSchool of Medicine

Philadelphia, Pennsylvania

Sripal Bangalore, MD, MHA

Associate Professor of MedicineDivision of Cardiology

Director of ResearchCardiac Catheterization LaboratoryDirector

Cardiovascular Outcomes GroupNew York University School of MedicineNew York, New York

Manish Bansal, MD

Assistant Professor of PediatricsDepartment of Pediatric CardiologyTexas Children’s Hospital/Baylor College

of MedicineHouston, Texas

Thomas Bartel, MD

Heart and Vascular InstituteCleveland Clinic

Abu Dhabi, United Arab Emirates

Rebecca Lynn Baumann, MD

FellowDepartment of CardiologyUMass Memorial Medical CenterWorcester, Massachusetts

Helmut Baumgartner, MD

DirectorDivision of Adult Congenital and ValvularHeart Disease

Department of Cardiovascular MedicineUniversity Hospital Muenster;

Professor of Cardiology/Adult CongenitalHeart Disease

Medical FacultyUniversity of MuensterMuenster, Germany

v

Roy Beigel, MD

The Heart Institute

Cedars Sinai Medical Center

Los Angeles, California;

The Leviev Heart Center

Sheba Medical Center at Tel Hashomer

Sackler School of Medicine

Tel Aviv University

Tel Aviv, Israel

J Todd Belcik, RCS, RDCS

Senior Research Associate/Research

Sonographer

Knight Cardiovascular Institute

Oregon Health & Science University

Assistant Professor of Medicine

Leon H Charney Division of Cardiology

New York University Langone Medical

Center

New York, New York

Eric Berkowitz, MD

Department of Cardiovascular Disease

Lenox Hill Hospital

New York, New York

Nicole M Bhave, MD

Department of Internal Medicine

Division of Cardiovascular Medicine

University of Michigan Medical Center

Ann Arbor, Michigan

Angelo Biviano, MD

Center for Interventional Vascular Therapy

Columbia University Medical Center

New York, New York

Nimrod Blank, MD

Division of Cardiology

Jewish General Hospital

Montreal, Quebec, Canada

Senior Staff CardiologistDepartment of CardiologyThe Prince Charles HospitalBrisbane, Queensland, Australia

Benjamin Byrd III, MD

ProfessorDepartment of MedicineVanderbilt University School of MedicineNashville, Tennessee

Scipione Carerj, MD

Cardiology InstitutionDepartment of Clinical and ExperimentalMedicine

University of MessinaMessina, Italy

John D Carroll, MD

DirectorCardiac and Vascular CenterDirector

Interventional CardiologyDivision of CardiologyUniversity of Colorado DenverAurora, Colorado

New York, New York

Geoff Chidsey, MD

Assistant ProfessorDepartment of CardiologyVanderbilt University Medical CenterNashville, Tennessee

Maurizio Cusma-Picconne, MD, PhD

Cardiology InstitutionDepartment of Clinical and ExperimentalMedicine

University of MessinaMessina, Italy

Abdellaziz Dahou, MD, MSc

Professor of MedicineDepartment of MedicineQuebec Heart and Lung InstituteQuebec, Quebec, Canada

Jacob P Dal-Bianco, MD

Department of CardiologyMassachusetts General HospitalBoston, Massachusetts

Daniel A Daneshvar, MD

Cardiology FellowNorth Shore LIJ/Lenox Hill HospitalNew York, New York

Melissa A Daubert, MD

Assistant Professor of MedicineDuke University Medical CenterDurham, North Carolina

Ravin Davidoff, MBBCh

Chief Medical OfficerSection of Cardiovascular MedicineBoston University School of MedicineBoston Medical Center

Lisa Dellefave-Castillo, MS, CGC

Genetic CounselorDepartment of MedicineThe University of ChicagoChicago, Illinois

Ankit A Desai, MD

Assistant Professor of MedicineDivision of CardiologySarver Heart CenterUniversity of ArizonaTucson, Arizona

Kavit A DeSouza, MD

Interventional Cardiology

Columbia University Division of

Cardiology

Mount Sinai Medical Center

Miami Beach, Florida

Bryan Doherty, MD

Cardiology Fellow

NS/LIJ Lenox Hill Hospital

New York, New York

Robert Donnino, MD

Assistant Professor of Medicine

Departments of Radiology and Medicine

New York University Langone Medical

Center

Department of Veterans Affairs

New York Harbor Healthcare System

New York, New York

Pamela S Douglas, MD, MACC,

Duke Clinical Research Institute

Durham, North Carolina

David M Dudzinski, MD, JD, FAHA

Fellow in Echocardiography

Cardiac Ultrasound Laboratory and

Critical Care Department

Massachusetts General Hospital

Boston, Massachusetts

Raluca Dulgheru, MD

GIGA Cardiovascular Sciences

Department of Cardiology

Heart Valve Clinic University of Lie´ge

University Hospital Sart Tilman

Quebec Heart and Lung Institute

Quebec, Quebec, Canada

Uri Elkayam, MD

Division of Cardiology

University of Southern California

Los Angeles, California

Raimund Erbel, MD, FASE, FAHA, FACC,

Elyse Foster, MD

Professor of MedicineAraxe Vilensky Endowed ChairCardiology

University of CaliforniaSan Francisco, California

Benjamin H Freed, MD

Assistant Professor of MedicineNorthwestern Memorial HospitalFeinberg School of MedicineChicago, Illinois

Julius M Gardin, MD, MBA

Professor and ChairDepartment of MedicineHackensack University Medical CenterHackensack, New Jersey;

ProfessorDepartment of MedicineRutgers New Jersey Medical SchoolNewark, New Jersey

Edward A Gill, MD

Professor of MedicineAdjunct Professor of RadiologyDepartments of Medicine and CardiologyUniversity of Washington;

Director of EchocardiographyHarborview Medical CenterSeattle, Washington

Linda Gillam, MD, MPH

ChairDepartment of Cardiovascular MedicineMorristown Medical Center

Morristown, New Jersey

Steven Giovannone, MD

Cardiology FellowLeon H Charney Division of CardiologyNew York University Langone MedicalCenter

New York, New York

Mark Goldberger, MD

Division of CardiologyDepartment of MedicineColumbia University College of Physiciansand Surgeons

New York, New York

Steven A Goldstein, MD, FACC

DirectorNoninvasive Cardiology LabWashington Hospital CenterWashington, DC

John Gorcsan III, MD

Professor of MedicineDepartment of CardiologyUniversity of PittsburghPittsburgh, Pennsylvania

Riccardo Gorla, MD

Department of CardiologyWest German Heart CentreEssen, Germany

Julia Grapsa, MD, PhD

Department of CardiologyHammersmith HospitalImperial College of LondonLondon, United Kingdom

Erin S Grawe, MD

Assistant Professor of ClinicalAnesthesia

Department of AnesthesiologyUniversity of Cincinnati Medical CenterCincinnati, Ohio

Christiane Gruner, MD

Department of CardiologyUniversity Heart CenterUniversity HospitalZurich, Switzerland

Pooja Gupta, MD, FAAP, FACC, FASE

Assistant Professor of PediatricsWayne State University School ofMedicine;

DirectorMichigan Adult Congenital Heart CenterChildren’s Hospital of MichiganDetroit, Michigan

Swaminatha Gurudevan, MD

Senior Clinical CardiologistDepartment of CardiologyHealthcare Partners Medical GroupPasadena, California

Rebecca T Hahn, MD, FACC, FASE

Columbia College of Physicians andSurgeons

Columbia University Medical CenterNew York, New York

Yuchi Han, MD, MMSc

Assistant ProfessorCardiovascular DivisionDepartment of MedicineUniversity of PennsylvaniaPhiladelphia, Pennsylvania

Jennifer L Hellawell, MD

FellowCardiovascular MedicineBoston Medical CenterBoston, Massachusetts

vii

Contributors

Samuel D Hillier, MBChB, MA, FRACP

Department of Echocardiography

The Prince Charles Hospital;

School of Medicine

University of Queensland

Brisbane, Queensland, Australia

Brian D Hoit, MD, FACC, FASE

Harrington Heart & Vascular Center

University Hospital Case Medical Center

Cleveland, Ohio

Richard Humes, MD, FAAP, FACC,

FASE

Professor of Pediatrics

Wayne State University School of Medicine;

Chief, Division of Cardiology

Children’s Hospital of Michigan

New York, New York;

Bloomberg School of Public Health

Johns Hopkins University

Baltimore, Maryland

Sanjiv Kaul, MD, FASE, FACC

Professor and Division Head

Aurora Health Care

Aurora Medical Group

Aurora/St Luke Medical Center;

Director, Echocardiography Center for

Research and Innovation

Aurora Research Institute;

Co-Director, Aurora Center forCardio-Oncology

Clinical Adjunct Professor of MedicineUniversity of Wisconsin School of MedicineMilwaukee, Wisconsin

Gene H Kim, MD

Assistant Professor of MedicineAdvanced Heart Failure and CardiacTransplantation

Institute of Cardiovascular ResearchDepartment of Medicine

University of ChicagoChicago, Illinois

Bruce J Kimura, MD, FACC

Medical DirectorCardiovascular Ultrasound LaboratoryScripps Mercy Hospital;

Associate Clinical ProfessorDepartment of CardiologyUniversity of CaliforniaSan Diego, California

Mary Etta King, MD

Associate Professor of PediatricsHarvard Medical School;

Staff EchocardiographerCardiac Ultrasound LaboratoryMassachusetts General HospitalBoston, Massachusetts

Dmitry Kireyev, MD

Clinical and Research Fellow in MedicineCardiac Ultrasound Laboratory

Cardiology DivisionDepartment of MedicineMassachusetts General HospitalBoston, Massachusetts

James N Kirkpatrick, MD

Assistant ProfessorCardiovascular Medicine DivisionDepartment of Medicine

Department of Medical Ethics and HealthPolicy

University of PennsylvaniaPhiladelphia, Pennsylvania

Allan L Klein, MD, FRCP(C), FACC,FAHA, FASE

Professor of MedicineCleveland Clinic Lerner College ofMedicine

Case Western Reserve University;

Director of Pericardial CenterCardiovascular MedicineHeart and Vascular InstituteCleveland Clinic

Cleveland, Ohio

Payal Kohli, MD

Division of CardiologyDepartment of MedicineUniversity of CaliforniaSan Francisco, California

Claudia E Korcarz, DVM, RDCS, FASE

Senior ScientistDepartment of MedicineCardiovascular Medicine DivisionUniversity of Wisconsin School ofMedicine and Public HealthMadison, Wisconsin

Smadar Kort, MD, FACC, FASE, FAHA

Professor of MedicineDirector of Cardiovascular ImagingDirector, Valve Center

Stony Brook University MedicineStony Brook, New York

Wojciech Kosmala, MD, PhD

ProfessorDepartment of CardiologyWroclaw Medical UniversityWroclaw, Poland

Konstantinos Koulogiannis, MD

Associate DirectorCardiovascular Core LabDepartment of Cardiovascular MedicineMorristown Medical Center

Gagnon Cardiovascular InstituteMorristown, New Jersey

Ilias Koutsogeorgis, MD

Department of CardiologyHammersmith HospitalImperial College of LondonLondon, United Kingdom

Frederick W Kremkau, PhD, FACR,FAIUM

Professor of Radiologic SciencesCenter for Applied LearningWake Forest University School ofMedicine

Winston-Salem, North Carolina

Eric V Krieger, MD

Assistant ProfessorDepartments of Medicine and CardiologyUniversity of Washington;

Director of EchocardiographyAdjunct Professor of RadiologyDepartments of Medicine and CardiologyHarborview Medical Center

Seattle, Washington

Itzhak Kronzon, MD, FASE, FACC,FAHA, FESC, FACP

Professor of MedicineDepartment of CardiologyHofstra University School of Medicine,and LIJ/North Shore Lenox Hill, HospitalNew York, New York

Richard T Kutnick, MD, FASE

Attending Physician

NS/LIJ Lenox Hill Hospital

New York, New York

Wyman Lai, MD, MPH, FACC, FASE

Professor of Pediatrics at CUMC

Division of Pediatric Cardiology

Columbia University Medical Center

New York, New York

Stephane Lambert, MD, FRCPC

Assistant Professor

Division of Cardiac Anesthesiology

University of Ottawa Heart Institute

Ottawa, Ontario, Canada

Patrizio Lancellotti, MD, PhD

Professor

GIGA Cardiovascular Sciences

Department of Cardiology

Heart Valve Clinic

University of Lie`ge Hospital

University Hospital Sart Tilman

The Chinese University of Hong Kong

Hong Kong, China

Ming Sum Lee, MD, PhD

Department of Cardiology

Kaiser Foundation Hospital

Los Angeles, California

Bruce Rappaport Faculty of Medicine

Technion–Israel Institute of Technology

Haifa, Israel

Steven J Lester, MD, FASE

Division of Cardiovascular Diseases

University of KentuckyLexington, Kentucky

Florent LeVen, MD

Department of CardiologyBrest University HospitalBrest, France;

ProfessorDepartment of MedicineLaval UniversityQuebec, Quebec, Canada

Robert A Levine, MD

Professor of MedicineCardiac Ultrasound LaboratoryMassachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts;

Fellow in Hypertrophic Cardiomyopathyand Echocardiography

Toronto General HospitalToronto, Ontario, Canada

Leo Lopez, MD, FACC, FAAP, FASE

Medical Director of Noninvasive CardiacImaging

Miami Children’s HospitalMiami, Florida

Julien Magne, PhD

Research AssociateGIGA Cardiovascular SciencesDepartment of CardiologyHeart Valve ClinicUniversity of Lie`ge HospitalUniversity Hospital Sart TilmanLie`ge, Belgium

Haifa Mahjoub, MD

Department of MedicineQuebec Heart and Lung InstituteLaval University

Quebec, Quebec, Canada

Judy R Mangion, MD

Division of Cardiovascular MedicineBrigham and Women’s HospitalHarvard Medical SchoolBoston, Massachussetts

Sunil V Mankad, MD, FASE

Associate Professor of MedicineDepartment of Cardiovascular DiseasesMayo Clinic

Rochester, Minnesota

Dimitrios Maragiannis, MD

Consultant CardiologistDepartment of Cardiology

401 General Army HospitalAthens, Greece;

Postdoctoral AssociateDepartment of CardiologyHouston Methodist HospitalHouston, Texas

Leo Marcoff, MD

Assistant Clinical Professor ofMedicine

Department of MedicineDivision of CardiologyColumbia UniversityNew York, New York

Randolph P Martin, MD

ChiefStructural and Valvular Heart DiseaseCenter of Excellence

Physician Principal AdvisorMarcus Heart Valve CenterPiedmont Heart Institute;

Emeritus Professor of MedicineEmory University School of MedicineAtlanta, Georgia

Moses Mathur, MD, MSc

Fellow in TrainingDepartment of MedicineSection of CardiologyTemple University HospitalPhiladelphia, Pennsylvania

Robert McCully, MD, MBChB

Professor of MedicineDivision of Cardiovascular Diseases andInternal Medicine

Mayo ClinicRochester, Minnesota

ix

Contributors

Edwin C McGee, MD

Surgical Director of Heart

Transplantation and Mechanical

Center for Genetic Medicine

Northwestern University Feinberg School

Clinical Associate Professor of Pediatrics

Department of Pediatric Cardiology

Cleveland Lerner College of Medicine

Cleveland Clinic Children’s Hospital

Cleveland, Ohio

Todd Mendelson, MD

Cardiology Fellow

Leon H Charney Division of Cardiology

New York University Langone Medical

Ichan School of Medicine at Mount Sinai

New York, New York

Mark Monaghan, MSc, PhD

Consultant Clinical Scientist

Director of Non-Invasive Cardiology

Kings College Hospital

London, United Kingdom

Farouk Mookadam, MD, MSc(HRM),

FRCPC, FACC

Consultant and Professor

Department of Cardiovascular Disease

Gillian Murtagh, MD

Cardiovascular Imaging FellowDepartment of CardiologyUniversity of ChicagoChicago, Illinois

Sherif F Nagueh, MD, FASE

Professor of MedicineWeill Cornell Medical College;

Medical DirectorEchocardiography LaboratoryMethodist DeBakey Heart and VascularCenter

Houston, Texas

Tasneem Z Naqvi, MD, FRCP(UK),MMM

Professor of MedicineDirector

Echocardiography LaboratoryDepartment of Internal MedicineDivision of Cardiology

Mayo ClinicScottsdale, Arizona

Sandeep Nathan, MD, MSc

Associate Professor of MedicineDirector

Interventional CardiologyUniversity of Chicago MedicineChicago, Illinois

Kazuaki Negishi, MD, PhD

Menzies Institute for Medical ResearchHobart, Tasmania, Australia

Petros Nihoyannopoulos, MD, FRCP,FESC, FACC, FAHA

ProfessorCardiology, NHLIImperial College LondonHammersmith HospitalLondon, United Kingdom

Vuyisile T Nkomo, MD, MPH

Associate Professor of MedicineDivision of Cardiovascular DiseasesMayo Clinic

Joan Olson, BS, RDCS, RVT

Division of CardiologyUniversity of Nebraska Medical CenterOmaha, Nebraska

John Palios, MD

Department of MedicineDivision of CardiologyEmory University School of MedicineAtlanta, Georgia

Gaurav Parikh, MBBS, MRCP(UK)

Cardiology FellowDepartment of CardiologyUniversity of Massachusetts MedicalSchool

Worcester, Massachusetts

Amit R Patel, MD

Department of MedicineUniversity of ChicagoChicago, Illinois

Amit V Patel

Cardiology FellowDepartment of CardiologyNew York University Medical CenterNew York, New York

Aneet Patel, MD

Chief Cardiovascular Diseases FellowDepartment of Medicine

Division of CardiologyUniversity of WashingtonSeattle, Washington

Anupa Patel, MBBCh(University ofWitwatersrand), FCP(SA), CertCardiology(SA)

Department of CardiologyChris Hani Baragwanath HospitalJohannesburg, South Africa

Mount Sinai School of Medicine

New York, New York

Patricia A Pellikka, MD, FACC,

FAHA, FASE

Director, Echocardiography Laboratory

Consultant, Division of Cardiovascular

Lenox Hill Hospital

New York, New York

Ferande Peters, MD

Department of Cardiology

Chris Hani Baragwanath Hospital

University of the Witwatersrand

Johannesburg, South Africa

Dermot Phelan, MD, PhD, BAO, BCh

Director, Sports Cardiology Center

Department of Cardiovascular Medicine

Quebec Heart and Lung Institute

Quebec, Quebec, Canada

Michael H Picard, MD, FASE

Director, Clinical Echocardiography

Juan Carlos Plana, MD, FASE

Chief of Clinical Operations

Don W Chapman Chair in Cardiology

Associate Professor of Medicine

Department of Cardiovascular Medicine

Heart and Vascular Institute

Cleveland Clinic

Cleveland, Ohio

Thomas Porter, MD

Division of CardiologyUniversity of Nebraska Medical CenterOmaha, Nebraska

Shawn C Pun, MD, FRCPC

Division of CardiologyJewish General HospitalMontreal, Quebec, Canada

Atif N Qasim, MD, MSCE

Assistant Professor of MedicineDivision of CardiologyUniversity of CaliforniaSan Francisco, California

Nishath Quader, MD

Assistant Professor of MedicineDivision of CardiologyWashington University in St Louis

St Louis, Missouri

Miguel A Quinones, MD

Houston Methodist DeBakey Heart &

Vascular CenterHouston, Texas

Peter S Rahko, MD, FACC, FASE

Professor of MedicineDepartment of MedicineDirector

Adult Echocardiography LaboratoryUniversity of Wisconsin School ofMedicine and Public HealthMadison, Wisconsin

Harry Rakowski, MD, FASE, FACC

Division of CardiologyToronto General HospitalUniversity Health NetworkToronto, Ontario, Canada

Rajeev V Rao, MD, FRCPC

Division of CardiologyRoyal Victoria Regional Health CentreBarrie, Ontario, Canada

Joseph Reiken, MSc

Principal EchocardiographerKing’s College HospitalLondon, United Kingdom

Shimon A Reisner, MD

Deputy DirectorRambam Health Care CampusBruce Rappaport Faculty of MedicineTechnion–Israel Institute of TechnologyHaifa, Israel

of Medicine;

Medical DirectorEchocardiography LaboratoryNorthwestern Memorial HospitalChicago, Illinois

David A Roberson, MD

Director of EchocardiographyHeart Institute for ChildrenAdvocate Children’s HospitalOak Lawn, Illinois

Keith Rodgers, RDCS

Cardiovascular SonographerEcho Lab

The Nebraska Medical CenterOmaha, Nebraska

Damian Roper, MBChB, FRACP

Department of EchocardiographyThe Prince Charles HospitalUniversity of QueenslandBrisbane, Queensland, Australia

Raphael Rosenhek, MD

DirectorHeart Valve ClinicDeparment of CardiologyMedical University of ViennaVienna, Austria

Eleanor Ross, MD

Attending PhysicianPediatric CardiologyAdvocate Children’s HospitalHeart Institute for ChildrenOak Lawn, Illinois

R Raina Roy, MD

Division of Cardiovascular DiseasesMayo Clinic College of MedicineScottsdale, Arizona

Lawrence G Rudski, MD, CM

DirectorDivision of CardiologyJewish General Hospital;

Associate Professor of MedicineMcGill University

Montreal, Quebec, Canada

Director of EchocardiographyUniversity of Colorado HospitalAurora, Colorado

Danita M Yoerger Sanborn, MD, MMSc

Cardiology DivisionMassachusetts General HospitalBoston, Massachusetts

xi

Contributors

Muhamed Saric, MD, PhD, FASE

Associate Professor of Medicine

Director, Echocardiography Lab

Leon H Charney Division of Cardiology,

New York University Langone Medical

Erasmus Medical Center

Rotterdam, The Netherlands

Shmuel S Schwartzenberg, MD

Clinical and Research Fellow in Medicine

Massachusetts General Hospital

Harvard Medical School

Mount Sinai School of Medicine

New York, New York

Pravin M Shah, MD, MACC

Chair and Medical Director

Hoag Heart Valve Center

Medical Director

Noninvasive Cardiac Imaging and

Academic Programs

Hoag Heart and Vascular Institute

Hoag Memorial Hospital Presbyterian

Newport Beach, California

Jack S Shanewise, MD, FASE

Professor of Clinical Anesthesiology

Department of Anesthesiology

Columbia University College of

Physicians & Surgeons

New York, New York

Assistant Professor of Medicine

Department of Internal Medicine

Division of Cardiovascular Medicine

Maithri Siriwardena, MBChB, PhD

Echocardiography FellowEchocardiography DepartmentToronto General HospitalToronto, Ontario, Canada

Samuel Siu, MD, SM, MBA

ProfessorDepartment of MedicineUniversity of Western OntarioLondon, Ontario, Canada

Scott D Solomon, MD

Professor of MedicineDepartment of Cardiovascular MedicineBrigham and Women’s HospitalBoston, Massachussetts

Program Director, AdvancedCardiovascular Imaging FellowshipProgram

Department of MedicineDivisions of Cardiovascular Medicine andRadiology

University of KentuckyLexington, Kentucky

Kirk T Spencer, MD

Professor of MedicineDepartment of MedicineSection of CardiologyUniversity of ChicagoChicago, Illinois

Denise Spiegel, RDCS

EchocardiographerDepartment of CardiologyAurora St Luke’s Medical CenterMilwaukee, Wisconsin

Martin St John Sutton, MBBS, FRCP

John Bryfogle Professor of MedicineUniversity of Pennsylvania

Philadelphia, Pennsylvania

James H Stein, MD, FASE

Professor of MedicineSchool of Medicine and Public HealthUniversity of Wisconsin

Paul E Szmitko, MD

Echocardiography FellowDivision of CardiologyToronto General HospitalToronto, Ontario, Canada

Tanya H Tajouri, MD

CardiologistUniversity of Minnesota Medical CenterMinneapolis, Minnesota

Masaaki Takeuchi, MD, FASE, FESC,FJCC

Associate ProfessorSecond Department of Internal MedicineUniversity of Occupational andEnvironmental HealthKitakyushu, Japan

James D Thomas, MD, FASE, FACC

Bluhm Cardiovascular InstituteNorthwestern UniversityChicago, Illinois

Dennis A Tighe, MD, FASE

Associate DirectorNoninvasive CardiologyProfessor of MedicineDivision of Cardiovascular MedicineUniversity of Massachusetts MedicalSchool

Worcester, Massachusetts

Maria C Todaro, MD

Cardiology UnitDepartment of Clinical and ExperimentalMedicine

University of MessinaMessina, Italy

Albree Tower-Rader, MD

Cardiology FellowCardiovascular MedicineCleveland Clinic FoundationCleveland, Ohio

Michael Y.C Tsang, MD

FellowCardiovascular DiseasesMayo Clinic

Rochester, Minnesota

Teresa S.M Tsang, MD, FRCPC,

FACC, FASE

Cardiologist and Echocardiographer

Professor and Associate Head

Research

Department of Medicine

The University of British Columbia

Diamond Health Care Centre

Vancouver, British Columbia, Canada

Wendy Tsang, MD, MS

Toronto General Hospital

University Health Network

Noninvasive Cardiology Laboratory

New York University Medical Center

New York, New York

Philippe Vignon, MD, PhD

Medical-Surgical Intensive Care Unit

Center of Clinical Investigation

INSERM 0635

Limoges Teaching Hospital

Limoges, France

Meagan M Wafsy, MD

Clinical and Research Fellow

Massachusetts General Hospital

Harvard Medical School

Boston, Massachusetts

Rachel Wald, MD, FRCPC

Pediatric and Adult Congenital

Cardiologist

Departments of Pediatrics, Medicine,

Medical Imaging, and

Obstetrics/Gynecology

University Health Network and Hospital

for Sick Children

University of Toronto

Toronto, Ontario, Canada

R Parker Ward, MD, FASE

DirectorDepartment of Clinical LaboratoryChief

Noninvasive Cardiovascular ImagingLaboratories

Miyazaki Medical Association HospitalMiyazaki, Japan

Kevin Wei, MD, FASE

Professor of MedicineKnight Cardiovascular InstituteOregon Health & Science UniversityPortland, Oregon

Neil J Weissman, MD, FASE, FACC

DirectorCardiovascular Core Laboratories;

PresidentMedstar Health Research Institute atWashington Hospital Center;

Professor of MedicineGeorgetown UniversityWashington, DC

Mariko Welsch, MD

Cardiology FellowUniversity of WashingtonSeattle, Washington

Susan Wiegers, MD, FASE, FACC

Senior Associate Dean of FacultyAffairs

ProfessorDepartment of MedicineSection of CardiologyTemple University HospitalPhiladelphia, Pennsylvania

Lynne Williams, MBBChB, PhD

Consultant CardiologistDepartment of CardiologyPapworth Hospital NHS Foundation TrustCambridge, United Kingdom

Anna Woo, MD, SM, FACC

Director, EchocardiographyDivision of CardiologyToronto General Hospital;

Associate Professor of MedicineUniversity of Toronto

Toronto, Ontario, Canada

Chanwit Wuttichaipradit, MD

Research FellowCleveland ClinicCleveland, Ohio

Feng Xie, MD

Division of CardiologyUniversity of Nebraska Medical CenterOmaha, Nebraska

Faculty of MedicineThe Chinese University of Hong KongHong Kong, China

Concetta Zito, MD, PhD

Assistant ProfessorUniversity of MessinaMessina, Italy

William A Zoghbi, MD, MACC, FAHA,FASE

Professor of MedicineDirector, Cardiovascular ImagingInstitute

Department of CardiologyHouston MethodistHouston, Texas

xiii

Contributors

It gives me great pleasure, as the president of the American Society

of Echocardiography (ASE), to introduce you toASE’s

Compre-hensive Echocardiography Conceived and executed by

editor-in-chief Roberto Lang, 2009/2010 president of the ASE, and senior

editors Steven Goldstein, Itzhak Kronzon, Bijoy Khandheria, and

Victor Mor-Avi, this book provides a comprehensive and practical

approach to the basic principles and clinical applications of

echo-cardiography It is a textbook and dynamic digital library for our

entire community With 200 chapters and 150 authors from across

the breadth of ASE expertise, there is something for everyone I am

confident this book will serve as a valuable resource for students,

early career clinicians, and advanced practitioners alike As

cardio-vascular ultrasound is used by more caregivers in more clinical

settings to answer more clinical questions, this textbook will become

more valuable The nicely illustrated print examples and easy-to-use

digital library with dynamic imaging videos will appeal to those

who both want to pull a book off the shelf and access information

on-the-go Given the expertise that went into this book and the ease

of use, I predict this will become the go-to textbook for our entirecardiovascular ultrasound community

I am also very proud that this textbook illustrates what is greatabout the ASE We are a society with more than 16,000 membersworldwide, dedicated to quality in cardiovascular ultrasound andeducation, both of which are prominently demonstrated throughoutthis textbook ASE is also a village made up of many different peo-ple from many different backgrounds, all united and energizedabout the value of cardiovascular ultrasound in caring for peopleworldwide Sharing knowledge, through this textbook, is one way

we come together as a community to further advance patient care.Enjoy the textbook, use it often and let it be just one of multiplelinks between you and the American Society of Echocardiography!

Neil J Weissman, MD, FASE, FACCPresident, American Society of Echocardiography, 2014-2015

xiv

For more than a quarter of a century, echocardiography has made

unparalleled contributions to clinical cardiology as a major tool for

real-time imaging of cardiac anatomy and physiology

Echocardi-ography is widely used every day in hospitals and clinics around the

world to assess cardiac function, and it provides invaluable,

nonin-vasive information for the diagnosis of multiple disease states The

American Society of Echocardiography (ASE) is an organization of

professionals committed to excellence in cardiovascular ultrasound

and its application to patient care through education, advocacy,

research, innovation, and service to our members and public

ASE ’s goal is to be its members’ primary resource for education,

knowledge exchange, and professional development The new

ASE’s Comprehensive Echocardiography is a major step toward

the achievement of this goal

This book is a result of a large-scale collaborative effort of multiple

ASE members who have contributed chapters on the topics of their

respective expertise Unlike other existing echocardiography

text-books, including the predecessor of this volume,Dynamic

Echocar-diography, published in 2011, this second edition—with its new

title—covers a full range of topics, as reflected by its staggering

200 chapters Our aim was to provide the essential material for each

topic in a succinct format, well-illustrated by multiple figures, tables,

and an extensive collection of online videos The ASE would like for

this comprehensive new textbook to replace the previously published

text Dynamic Echocardiography, which was widely successful

among our readers Although some of the topics remain the same,

understandably, the material, including text, figures, and references,

was almost entirely rewritten to provide up-to-date information that

takes into account the clinical and technological advancements that

took place since the previous publication

Once readers have reviewed the written chapters, we encourage

them to review the accompanying online videos of corresponding

cardiac pathologies We believe that this combined approach is themost effective way of learning clinical echocardiography Our hope

is that physicians and cardiac sonographers will use this text and itscompanion material as a reference and educational aide in echocar-diography laboratories around the world

The ASE and the editors thank the authors for selflessly uting their time, effort, and expertise for the completion and success

contrib-of this project We also wish to thank the sonographers, who withtheir expert hands have generated and provided the spectacularimages that illustrate this text, without which this educationalendeavor would not have been possible

The editors also want to thank our ASE colleagues, who havetirelessly worked with us on this project from conception to fru-ition, including Hilary Lamb and Robin Wiegerink, as well asthe expert help of the Elsevier staff We also thank the ASE board

of directors and the executive committee for their support, agement, and valuable comments and suggestions

encour-We also wish to thank our families for their continuous supportwhile we worked on this project: our spouses, Lili, Simoy, Ziva,Andy, and Priti; our children, Daniella, Gabriel, Lindsey, Lauren,Derek, Iris, Rafi, Shira, Eden, Yarden, Vishal, and Trishala; and ourgrandchildren, Ella, Adam, Lucy, Eli, and Jacob

Roberto M Lang, MD, FASE, FACC, FAHA, FESC, FRCP

Steven A Goldstein, MD, FACCItzhak Kronzon, MD, FASE, FACC, FAHA, FESC, FACPBijoy K Khandheria, MD, FASE, FACC, FESC, FACP

Victor Mor-Avi, PhD, FASE

xv

1 General Principles of Echocardiography, 1

Marek Belohlavek, MD, PhD, Tasneem Z Naqvi, MD

5 Tissue Harmonic Imaging, 17

Joan Olson, BS, RDCS, RVT, Keith Rodgers, RDCS, Feng Xie, MD,

Thomas Porter, MD

SECTION II Transthoracic

Echocardiography

6 Transthoracic Echocardiography: Nomenclature

and Standard Views, 19

Meagan M Wasfy, MD, Michael H Picard, MD

7 Technical Quality, 24

Bonita Anderson, DMU (Cardiac), M Appl Sc (Med Ultrasound)

8 Transthoracic Echocardiography Tomographic

Views, 26

Wendy Tsang, MD, MS, Roberto M Lang, MD,

Itzhak Kronzon, MD

9 M-Mode Echocardiography, 30

Itzhak Kronzon, MD, Gerard P Aurigemma, MD

10 Doppler Echocardiography: Normal Antegrade

Flow Patterns, 39

Mohamed Ahmed, MD, Gerard P Aurigemma, MD

SECTION III Transesophageal

Thomas Bartel, MD, Silvana Mu¨ller, MD, Angelo Biviano, MD, Rebecca T Hahn, MD

16 Limitations of IntracardiacEchocardiography, 71

Thomas Bartel, MD, Silvana Mu¨ller, MD, Angelo Biviano, MD, Rebecca T Hahn, MD

SECTION VI Hand-Held Echocardiography

19 Hand-Carried Cardiac Ultrasound: Background,Instrumentation, and Technique, 85

22 Ultrasound Contrast Agents, 91

Joan Olson, BS, RDCS, RVT, Feng Xie, MD, Thomas Porter, MD

23 Physical Properties of Microbubble UltrasoundContrast Agents, 94

26 Contrast-Enhanced Carotid Imaging, 107

Arend F.L Schinkel, MD, PhD, Blai Coll, MD, Steven B Feinstein, MD

xvi

SECTION VIII Left Ventricular Systolic Function

Zoran B Popovic´, MD, PhD, James D Thomas, MD

29 Global Left Ventricular Systolic Function, 120

Alex Pui-Wai Lee, MBChB, Cheuk-Man Yu, MD

30 Regional Left Ventricular Systolic Function, 124

Manish Bansal, MD, Partho P Sengupta, MD, DM

31 Assessment of Left Ventricular

Dyssynchrony, 128

John Gorcsan III, MD, Antonia Delgado-Montero, MD

32 Right Ventricular Anatomy, 139

Judy R Mangion, MD, Scott D Solomon, MD

33 The Physiologic Basis of Right Ventricular

Echocardiography, 142

Payal Kohli, MD, Nelson B Schiller, MD

34 Assessment of Right Ventricular Systolic and

Diastolic Function, 151

Lawrence G Rudski, MD, Denisa Muraru, MD, PhD,

Jonathan Afilalo, MD, MSc, Steven J Lester, MD

35 Right Ventricular Hemodynamics, 158

Steven J Lester, MD, Lawrence G Rudski, MD, Amr E Abbas, MD

36 The Right Atrium, 161

Nimrod Blank, MD, Julia Grapsa, MD, PhD,

Monica Mukherjee, MD, Theodore Abraham, MD

40 Echo Doppler Parameters of Diastolic

42 Clinical Recommendations for Echocardiography

Laboratories for Assessment of Left Ventricular

Diastolic Function, 187

Sherif F Nagueh, MD, FASE

43 Newer Methods to Assess Diastolic Function, 190

Gianni Pedrizzetti, PhD, Prtho P Segupta, MD, DM

44 Causes of Diastolic Dysfunction, 193

Rebecca Lynn Baumann, MD, Gerard P Aurigemma, MD

SECTION XI Left Atrium

45 Assessment of Left Atrial Size, 199

Teresa S M Tsang, MD

46 Assessment of Left Atrial Function, 203

Brian D Hoit, MD

47 Introduction to Ischemic Heart Disease, 209

Pamela S Douglas, MD, MACC

48 Ischemic Heart Disease: Basic Principles, 209

Shmuel S Schwartzenberg, MD, Michael H Picard, MD

49 Acute Chest Pain Syndromes: DifferentialDiagnosis, 211

Federico M Asch, MD, Neil J Weissman, MD

50 Echocardiography in Acute MyocardialInfarction, 215

Michael Y.C Tsang, MD, Tanya H Tajouri, MD, Sunil V Mankad, MD

51 Echocardiography in Stable Coronary ArteryDisease, 220

Benjamin Byrd III, MD, Geoff Chidsey, MD

52 Old Myocardial Infarction, 222

Yuchi Han, MD, MMSc, Martin G St John Sutton, MBBS

53 End-Stage Cardiomyopathy due to CoronaryArtery Disease, 227

Peter S Rahko, MD

54 Coronary Artery Anomalies, 230

Aneet Patel, MD, Eric V Krieger, MD, Mariko Welch, MD, Edward A Gill, MD

55 Stress Echocardiography: Introduction, 237

57 Diagnostic Criteria and Accuracy, 241

Kavit A Desouza, MD, Farooq A Chaudhry, MD

58 Stress Echocardiography Methodology, 244

R Raina Roy, MD, Robert McCully, MD, MBChB, Steven J Lester, MD

59 Stress Echocardiography: ImageAcquisition, 248

David M Dudzinski, MD, JD, Michael H Picard, MD

60 Prognosis, 251

Vikram Agarwal, MD, MPH, Farooq A Chaudhry, MD

61 Viability, 254

Sripal Bangalore, MD, MHA, Farooq A Chaudhry, MD

62 Contrast-Enhanced Stress Echocardiography, 260

Feng Xie, MD, Joan Olson, BS, RDCS, RVT, Thomas Porter, MD

63 Three-Dimensional Stress Echocardiography, 268

Mark Monaghan, MSc, PhD, Joseph Reiken, MSc, Steven A Goldstein, MD

xvii

Contents

64 Stress Echocardiography for Valve Disease: Aortic

Regurgitation and Mitral Stenosis, 274

Patrizio Lancellotti, MD, PhD, Julien Magne, PhD

65 Appropriate Use Criteria for Stress

Echocardiography, 277

R Parker Ward, MD

66 Comparison with Other Techniques, 279

Azhar A Supariwala, MD, Farooq A Chaudhry, MD

SECTION XIV Cardiomyopathies

69 Hypertrophic Cardiomyopathy: Pathophysiology,

Functional Features, and Treatment of Outflow

Tract Obstruction, 290

Paul E Szmitko, MD, Anna Woo, MD, SM

70 Differential of Hypertrophic Cardiomyopathy

versus Secondary Conditions That Mimic

Hypertrophic Cardiomyopathy, 294

Christiane Gruner, MD, Lynne Williams, MBBChB, PhD,

Harry Rakowski, MD

71 Echocardiographic Features of Hypertrophic

Cardiomyopathy: Mechanism of Systolic Anterior

Motion, 302

Pravin M Shah, MD, MACC

72 Hypertrophic Cardiomyopathy: Assessment of

Therapy, 307

Paul E Szmitko, MD, Anna Woo, MD, SM

73 Hypertrophic Cardiomyopathy: Screening of

Relatives, 312

Anna Woo, MD, SM, Maithri Siriwardena, MBChB, PhD

74 Apical Hypertrophic Cardiomyopathy, 314

Steven A Goldstein, MD

75 Echocardiography in Athletic Preparticipation

Screening, 319

Denise Spiegel, RDCS, Timothy E Paterick, MD, JD

76 Dilated Cardiomyopathy: Etiology,

Diagnostic Criteria, and Echocardiographic

78 Echocardiographic Predictors of Outcome in

Patients with Dilated Cardiomyopathy, 333

Federico M Asch, MD, Neil J Weissman, MD

79 Right Ventricle in Dilated Cardiomyopathy, 337

Shawn C Pun, MD, Lawrence G Rudski, MD, CM

80 Restrictive Cardiomyopathy: Classification, 341

Beatriz Ferreira, MD, PhD, Ferande Peters, MD

84 Restriction versus Constriction, 358

Karen Modesto, MD, Partho Sengupta, MD, DM

85 Echocardiography in Arrhythmogenic RightVentricular Cardiomyopathy, 362

Danita M Yoerger Sanborn, MD, MMSc

86 Echocardiographic Analysis of Left VentricularNoncompaction, 366

Denise Spiegel, RDCS, Timothy E Paterick, MD, JD

87 Takotsubo-like Transient Left VentricularDysfunction: Takotsubo Cardiomyopathy, 368

Sourin Banerji, MD, James N Kirkpatrick, MD

Danita M Yoerger Sanborn, MD

92 Echocardiographic Evaluation of FunctionalTricuspid Regurgitation, 384

Denise Spiegel, RDCS, Timothy E Paterick, MD, JD

93 Echocardiographic Evaluation of the Right Heart:Limitations and Technical Considerations, 386

David B Adams, RCS, RDCS

SECTION XV Aortic Stenosis

94 Aortic Stenosis Morphology, 389

99 Low-Flow, Low-Gradient Aortic Stenosis with

Preserved Left Ventricular Ejection

Fraction, 422

Florent LeVen, MD, Philippe Pibarot, DVM, PhD,

Jean G Dumesnil, MD

100 Stress (Exercise) Echocardiography in

Asymptomatic Aortic Stenosis, 426

Patrizio Lancellotti, MD, PhD, Raluca Dulgheru, MD

101 Subaortic Stenosis, 431

Daniel A Daneshvar, MD, Itzhak Kronzon, MD

102 Introduction to Aortic Regurgitation, 437

Issam A Mikati, MD, Robert O Bonow, MD, MS

103 Aortic Regurgitation: Etiologies and Left

Ventricular Responses, 438

Nicole M Bhave, MD

104 Aortic Regurgitation: Pathophysiology, 442

Roy Beigel, MD, Robert J Siegel, MD

105 Quantitation of Aortic Regurgitation, 446

Hari P Chaliki, MD, Vuyisile T Nkomo, MD, MPH

106 Risk Stratification: Timing of Surgery for Aortic

Regurgitation, 450

Ricardo Benenstein, MD, Muhamed Saric, MD, PhD

107 Mitral Stenosis: Introduction, 453

Itzhak Kronzon, MD, Roberto M Lang, MD, Muhamed Saric,

MD, PhD

108 Rheumatic Mitral Stenosis, 454

Muhamed Saric, MD, PhD, Roberto M Lang, MD,

Itzhak Kronzon, MD

109 Quantification of Mitral Stenosis, 460

Muhamed Saric, MD, PhD, Roberto M Lang, MD,

Itzhak Kronzon, MD

110 Other (Nonrheumatic) Etiologies of Mitral Stenosis;

Situations That Mimic Mitral Stenosis, 465

112 Consequences of Mitral Stenosis, 471

Wendy Tsang, MD, MS, Roberto M Lang, MD

SECTION XVIII Mitral Regurgitation

113 Introduction to Mitral Regurgitation, 477

115 Mitral Valve Prolapse, 481

Wendy Tsang, MD, MS, Benjamin H Freed, MD,

Roberto M Lang, MD

116 Quantification of Mitral Regurgitation, 484

Wendy Tsang, MD, MS, Benjamin H Freed, MD, Roberto M Lang, MD

117 Asymptomatic Severe Mitral Regurgitation, 492

Raphael Rosenhek, MD

118 Role of Exercise Stress Testing, 495

Patrizio Lancellotti, MD, PhD, Marie Moonen, MD, PhD, Julien Magne, PhD

119 Ischemic Mitral Regurgitation, 500

Jacob P Dal-Bianco, MD, Robert A Levine, MD, Steven A Goldstein, MD

SECTION XIX Tricuspid Regurgitation

120 Epidemiology, Etiology, and Natural History

of Tricuspid Regurgitation, 511

Luigi P Badano, MD, PhD, Karima Addetia, MD, Denisa Muraru, MD, PhD

121 Quantification of Tricuspid Regurgitation, 517

Luigi P Badano, MD, PhD, Karima Addetia, MD, Denisa Muraru, MD, PhD

122 Indications for Tricuspid Valve Surgery, 523

Stanton K Shernan, MD, Stephane Lambert, MD

123 Tricuspid Valve Procedures, 526

Stanton K Shernan, MD, Stephane Lambert, MD

124 Introduction and Etiology of PulmonicRegurgitation, 529

Melissa A Daubert, MD, Smadar Kort, MD

125 Pulmonic Regurgitation: Semiquantification, 532

Kelly Axsom, MD, Muhamed Saric, MD, PhD

126 Prosthetic Valves: Introduction, 537

William A Zoghbi, MD, MACC

127 Classification of Prosthetic Valve Typesand Fluid Dynamics, 542

Haı¨fa Mahjoub, MD, Jean G Dumesnil, MD, Philippe Pibarot, DVM, PhD

128 Aortic Prosthetic Valves, 550

Damian Roper, MBChB, Darryl J Burstow, MBBS

129 Mitral Prosthetic Valves, 555

Samuel D Hillier, MBChB, MA, Darryl J Burstow, MBBS

130 Periprosthetic Leaks, 559

Gila Perk, MD, Itzhak Kronzon, MD, Carlos Ruiz, MD, PhD

131 Tricuspid Prosthetic Valves, 564

Dimitrios Maragiannis, MD, Sherif F Nagueh, MD

132 Mitral Valve Repair, 570

Stanton K Shernan, MD

SECTION XXII Infective Endocarditis

133 Introduction and Echocardiographic Features

of Infective Endocarditis, 575

Moses Mathur, MD, MSc, Susan Wiegers, MD

xix

Contents

134 Infective Endocarditis: Role of Transthoracic

versus Transesophageal Echocardiography, 577

Maria C Todaro, MD, Concetta Zito, MD, PhD,

Scipione Carerj, MD, Bijoy K Khandheria, MD

135 Echocardiography for Prediction of

Cardioembolic Risk, 580

Ferande Peters, MD, Bijoy K Khandheria, MD

136 Echocardiography and Decision Making for

Surgery, 584

Laila A Payvandi, MD, Vera H Rigolin, MD

137 Intraoperative Echocardiography in Infective

Endocarditis, 586

Nishath Quader, MD, Edwin C McGee, MD, Vera H Rigolin, MD

138 Limitations and Technical Considerations, 588

Rebecca T Hahn, MD

SECTION XXIII Pericardial Diseases

139 Introduction to Pericardial Diseases, 593

Itzhak Kronzon, MD

140 Normal Pericardial Anatomy, 595

Steven Giovannone, MD, Robert Donnino, MD,

Muhamed Saric, MD, PhD

141 Pericarditis, 599

Sonia Jain, MD, MBBS, Sunil V Mankad, MD

142 Pericardial Effusion and Cardiac

144 Effusive Constrictive Pericarditis, 611

Eric Berkowitz, MD, Itzhak Kronzon, MD

145 Pericardial Cysts and Congenital Absence of the

Teerapat Yingchoncharoen, MD, Allan L Klein, MD

147 Primary Benign, Malignant, and Metastatic

Tumors in the Heart, 618

Zoe Yu, MD, Gillian Murtagh, MD, Jeanne M DeCara, MD

148 Left Ventricular Thrombus, 624

Amr E Abbas, MD, Steven J Lester, MD

149 Left Atrial Thrombus, 627

Yoram Agmon, MD, Jonathan Lessick, MD, DSc,

Shimon A Reisner, MD

150 Right Heart Thrombi, 633

Vincent L Sorrell, MD, Vrinda Sardana, MD, Steve W Leung, MD

151 Normal Anatomic Variants and Artifacts, 640

Steven A Goldstein, MD

152 Role of Contrast Echocardiography in theAssessment of Intracardiac Masses, 647

James N Kirkpatrick, MD, Roberto M Lang, MD

153 Echocardiography-Guided Biopsy of IntracardiacMasses, 652

Gaurav Parikh, MBBS, Jeffrey A Shih, MD, Dennis A Tighe, MD

154 Cardiac Sources of Emboli, 656

Kirk T Spencer, MD

155 Introduction, 659

Arturo A Evangelista, MD

156 Aortic Atherosclerosis and Embolic Events, 660

Itzhak Kronzon, MD, Paul A Tunick, MD

157 Aortic Aneurysm, 663

Arturo A Evangelista, MD

158 Sinus of Valsalva Aneurysm, 666

Farouk Mookadam, MD, MSc(HRM)

159 Acute Aortic Syndrome, 671

Muhamed Saric, MD, PhD, Itzhak Kronzon, MD

160 Penetrating Atherosclerotic Ulcer andIntramural Hematoma, 680

Raimund Erbel, MD, Sofia Churzidse, MD, Riccardo Gorla, MD, Alexander Janosi, MD

161 Aortic Trauma, 687

Philippe Vignon, MD, PhD, Pierre Massabuau, MD, Roberto M Lang, MD

162 Intraoperative Echocardiography, 691

Erin S Grawe, MD, Jack S Shanewise, MD

163 Postoperative Echocardiography of theAorta, 694

Steven A Goldstein, MD

SECTION XXVI Adult Congenital Heart Disease

164 Introduction, 701

Mary Etta King, MD

165 Systematic Approach to Adult Congenital HeartDisease, 703

Pooja Gupta, MD, Richard Humes, MD

166 Common Congenital Heart Defects Associatedwith Left-to-Right Shunts, 709

Eleanor Ross, MD, Vivian W Cui, MD, David A Roberson, MD

167 Obstructive Lesions, 718

Leo Lopez, MD, Wyman Lai, MD, MPH

168 The Adult with Unrepaired Complex CongenitalHeart Defects, 723

Rachel Wald, MD, Samuel Siu, MD, SM, MBA, Erwin Oechslin, MD

169 Adult Congenital Heart Disease with PriorSurgical Repair, 730

Richard Humes, MD, Pooja Gupta, MD

SECTION XXVII Systemic Diseases

170 Hypertension, 739

Brian D Hoit, MD

171 Diabetes, 742

Peter A Kahn, BA, Julius M Gardin, MD, MBA

172 End-Stage Renal Disease, 746

Mark Goldberger, MD

173 Obesity, 751

Sudhir Ken Mehta, MD, MBA, Francine Erenberg, MD

174 Rheumatic Fever and Rheumatic Heart

Disease, 754

Ferande Peters, MD, Bijoy K Khandheria, MD

175 Systemic Lupus Erythematosus, 757

Rajeev V Rao, MD, Kwan-Leung Chan, MD

176 Antiphospholipid Antibody Syndrome, 760

Rajeev V Rao, MD, Kwan-Leung Chan, MD

177 Carcinoid Heart Disease, 763

Albree Tower-Rader, MD, Vera H Rigolin, MD

178 Amyloid, 765

Revathi Balakrishnan, MD, Muhamed Saric, MD, PhD

179 Sarcoidosis, 769

Amit V Patel, MD, Gillian Murtagh, MD, Amit R Patel, MD

180 Cardiac Involvement in Hypereosinophilic

183 Sickle Cell Disease, 783

Ankit A Desai, MD, Amit R Patel, MD

184 Human Immunodeficiency Virus, 786

Edgar Argulian, MD, MPH, Farooq A Chaudhry, MD

185 Cardiotoxic Effects of Cancer Therapy, 788

Juan Carlos Plana, MD

186 Pregnancy and the Heart, 797

Tasneem Z Naqvi, MD, Ming Sum Lee, MD, PhD,

Uri Elkayam, MD

187 Cocaine, 801

Sudhir Ken Mehta, MD, MBA, Swaminatha Gurudevan, MD

Emergency Department

188 Echocardiography in Emergency Clinical

Presentation, 805

J Todd Belcik, RCS, RDCS, Jonathan R Lindner, MD

Echocardiography

189 Introduction, 809

Ernesto E Salcedo, MD, John D Carroll, MD

190 Transcatheter Aortic Valve Replacement, 814

Linda D Gillam, MD, MPH, Konstantinos Koulogiannis, MD, Leo Marcoff, MD

191 MitraClip Procedure, 818

Julia Grapsa, MD, PhD, Ilias D Koutsogeorgis, MD, Petros Nihoyannopoulos, MD, Ferande Peters, MD, Bijoy K Khandheria, MD

192 Mitral Balloon Valvuloplasty, 823

Michael S Kim, MD, Ernesto E Salcedo, MD

193 Transcatheter Valve-in-ValveImplantation, 828

Itzhak Kronzon, MD, Carlos Ruiz, MD, PhD, Gila Perk, MD

194 Atrial and Ventricular Septal DefectClosure, 831

Todd Mendelson, MD, Carlos Alviar, MD, Muhamed Saric, MD, PhD

195 Transcatheter Cardiac PseudoaneurysmClosure, 837

Itzhak Kronzon, MD, Carlos Ruiz, MD, PhD, Gila Perk, MD

196 Patent Foramen Ovale, 840

Anupa Patel, MBBCh, Ferande Peters, MD, Bijoy K Khandheria, MD

197 Fusion of Three-DimensionalEchocardiography with Fluoroscopy forInterventional Guidance, 845

John D Carroll, MD, Ernesto E Salcedo, MD

SECTION XXX Miscellaneous Topics

James H Stein, MD, Claudia E Korcarz, DVM, RDCS

200 Coronary Artery Imaging, 855

Masaaki Takeuchi, MD

xxi

Contents

I Physics and Instrumentation

1 General Principles of Echocardiography

Frederick W Kremkau, PhD

Echocardiography is sonography of the heart.Sonography comes

from the Latinsonus (sound) and the Greek graphein (to write)

Diagnostic sonography is medical real-time, two-dimensional

(2D) and three-dimensional (3D) anatomic and flow imaging using

ultrasound Ultrasound is sound of frequency higher than what

humans can hear Frequencies used in echocardiography range

from about 2 MHz for adult transthoracic studies to about 7 MHz

for higher-frequency applications such as harmonic imaging and

pediatric and transesophageal studies Ultrasound provides a

non-invasive view of the heart Echocardiography is accomplished with

a pulse-echo technique Pulses of ultrasound, two to three cycles

long, are generated by a transducer (Fig 1.1) and directed into

the patient, where they produce echoes at organ boundaries and

within tissues These echoes then return to the transducer, where

they are detected and presented on the display of a sonographic

instrument (Fig 1.2) The ultrasound instrument processes the

ech-oes and presents them as visible dots, which form the anatomic

image on the display The brightness of each dot corresponds to

the echo strength, producing what is known as agrayscale image

The location of each dot corresponds to the anatomic location of the

echo-generating object Positional information is determined by

knowing the path of the pulse as it travels and measuring the time

it takes for each echo to return to the transducer From a starting

point at the top of the display, the proper location for presenting

each echo is determined Because the speed of the sound wave is

known, the echo arrival time can be used to determine the depth

of the object that produced the echo

When a pulse of ultrasound is sent into tissue, a series of dots

(one scan line, data line, or echo line) is displayed Not all of the

ultrasound pulse is reflected from any single interface Rather, most

of the original pulse continues into the tissue and is reflected from

deeper interfaces The echoes from one pulse appear as one scan

line Subsequent pulses go out in slightly different directions from

the same origin The result is a sector scan (sector image), which is

shaped like a slice of pie (Fig 1.3) The resulting cross-sectional

image is composed of many (typically 96 to 256) of these scan

lines For decades, sonography was limited to 2D cross-sectional

scans (or slices) through anatomy such as that inFigure 1.3 2D

imaging has been extended into 3D scanning and imaging, also

calledvolume imaging, as described in Chapter 2 This requires

scanning the ultrasound through many adjacent 2D tissue cross

sec-tions to build up a 3D volume of echo information, like a loaf of

sliced bread (Fig 1.4) In addition to anatomic grayscale imaging,

stationary beam, M-mode presentations provide depth versus time

recordings of moving objects (Fig 1.5)

TRANSDUCER

The transducer used in echocardiography is a phased array that

electronically steers the ultrasound beam in the sector format It

is energized by an electrical voltage from the instrument that

pro-duces the outgoing ultrasound pulse The returning echo stream is

received by the transducer and converted to an echo voltage stream

that is sent to the instrument, ultimately appearing on the display as

a scan line This process occurs a few thousand times per second(called thepulse repetition frequency [PRF]) A coupling gel isused between the transducer and the skin to eliminate the air thatwould block the passage of ultrasound across that boundary Trans-ducers are designed for transthoracic and for transesophageal imag-ing (seeFig 1.1) The latter provides a shorter acoustic path (withless attenuation, allowing higher frequency and improved resolu-tion) to the heart that avoids intervening lung and ribs

INSTRUMENT

An echocardiographic instrument has a functional block diagram asshown inFigure 1.6 The beam former drives the transducer andreceives the returning echo streams, amplifying (this is calledgain)and digitizing them Attenuation compensation occurs in the recep-tion side of the beam former The signal processor, among otherfunctions, detects the strength (amplitude) of each echo voltage.Echo amplitudes are stored as numbers in the image memory,which is part of the image processor Upon completion of a singlescan (one frame of a real-time presentation), the stored image issent to the display The display is a flat-panel screen, now common

in computer monitors and television sets The echo information issent into the image memory in ultrasound scan lines in sector for-mat, but it is read out and sent to the display in horizontal displayline format, with each horizontal line on the display corresponding

to a row of echo data in the image memory

Some artifacts are produced by improper equipment operation

or settings (e.g., incorrect gain and compensation settings) Otherartifacts are inherent in the sonographic methods and can occureven with proper equipment and technique The assumptions inher-ent in the design of sonographic instruments include the following:

• Sound travels in straight lines

• Echoes originate only from objects located on the beam axis

• The amplitude of returning echoes is related directly to thereflecting or scattering properties of distant objects

• The distance to reflecting or scattering objects is proportional tothe round-trip travel time at a speed of 1.54 mm/μs

If any of these assumptions are violated, an artifact occurs

Figure 1.7 and Video 1.7, A to D, provide examples of cardiacartifacts

1

Figure 1.1 A, Transthoracic transducer B, Transesophageal transducer.

Figure 1.2 Echocardiographic instrument.

Figure 1.3 2D cardiac sector image.

Live 3DApical four chamber

75bpmM2

Figure 1.4 3D cardiac image.

T i m e

Depth

A

M

Figure 1.5 M-mode display A (amplitude)-mode is shown on the right, and the 2D sector scan at the upper left M (motion)-mode is depth on the vertical axis versus time on the horizontal axis.

Signalprocessor

Beamformer

T

Imageprocessor

Display

Figure 1.6 Block diagram of echocardiographic instrument.

Information derived from in vitro and in vivo experimental studies

has yielded no known risks in the use of echocardiography

Ther-mal and mechanical mechanisms have been considered but do not

appear to be operating significantly at diagnostic intensities

Exper-imental animal data have helped to define the intensity–exposure

time region in which bioeffects can occur However, differences,

physical and biological, between the two situations make it difficult

to apply results from one risk assessment to the other In the

absence of known risk, it is still necessary to remember that

bioef-fects not yet identified could occur Therefore, a conservative

approach to the medical use of ultrasound is recommended

Epidemiologic studies have revealed no known risk associated

with the use of diagnostic ultrasound Experimental animal studies

have shown that with most equipment, bioeffects occur only at

intensities higher than those expected at relevant tissue locations

during ultrasound imaging and flow measurements Thus a

compar-ison of instrument output data adjusted for tissue attenuation with

experimental bioeffects data does not indicate any risk We must be

open, however, to the possibility that unrecognized, but not zero,

risk may exist Such risk, if it does exist, may have eluded detection

up to this point because it is subtle or delayed, or its incidence is

close to normal values As more sensitive end points are studied

over longer periods or with larger populations, such risks may be

identified However, future studies might not reveal any

detrimen-tal effects, thus strengthening the possibility that medical

ultra-sound imaging is without detectable risk In the meantime, with

no known risk and with known benefit to the procedure, a vative approach to imaging should still be used That is, ultrasoundimaging should be used when medically indicated, with minimumexposure to the patient Exposure is limited by minimizing bothinstrument output and exposure time during a study

conser-Following is the April 1, 2012, American Institute of Ultrasound

in Medicine (AIUM) Official Statement on Prudent Use and ical Safety:

Clin-Diagnostic ultrasound has been in use since the late 1950s.Given its known benefits and recognized efficacy for medicaldiagnosis, including use during human pregnancy, theAmerican Institute of Ultrasound in Medicine herein addressesthe clinical safety of such use: No independently confirmedadverse effects caused by exposure from present diagnosticultrasound instruments have been reported in human patients inthe absence of contrast agents Biological effects (such aslocalized pulmonary bleeding) have been reported inmammalian systems at diagnostically relevant exposures but theclinical significance of such effects is not yet known Ultrasoundshould be used by qualified health professionals to providemedical benefit to the patient Ultrasound exposures duringexaminations should be as low as reasonably

achievable (ALARA)

The AIUM statement provides an excellent basis for formulating aresponse to patient questions and concerns Prudence in practice isexercised by minimizing exposure time and output Display ofinstrument outputs in the form of thermal and mechanical indexes(TIs and MIs, respectively) facilitates such prudent use

In decades of use, there have been no reports of injury to patients

or to operators from medical ultrasound equipment We in the sound community want to maintain that level of safety In the past,application-specific output limits and the user’s knowledge of equip-ment controls and patient body characteristics were the means ofminimizing exposure Now more information is available Themechanical and thermal indexes provide users with information thatcan be applied specifically to formulate ALARA guidelines Values

ultra-of these indexes eliminate some ultra-of the guesswork and indicate theactual physiologic effects within the patient and what occurs whencontrol settings are changed These values make it possible for theuser to obtain the best image possible while following the ALARAprinciple, thus maximizing the benefits and minimizing the risks.Advanced features and techniques (3D echocardiography,Doppler, tissue Doppler imaging, speckle tracking echo, tissue har-monic imaging) are covered in more detail in this book Expansion

of all the topics covered in this chapter can be found elsewhere.1

Please access ExpertConsult to see Video 1.7,A to D

REFERENCE

1 Kremkau FW: Sonography: Principles and Instruments, ed 9, Philadelphia,

In press, WB Saunders.

2 Three-Dimensional Echocardiography

Luigi P Badano, MD, PhD, Denisa Muraru, MD, PhD

The milestone in the evolution of three-dimensional

echocardiog-raphy (3DE) from two-dimensional echocardiogechocardiog-raphy (2DE) has

been the development of fully sampled matrix array transthoracic

transducers based on advanced digital processing and improved

image formation algorithms This allowed the operators to obtaintransthoracic real-time volumetric imaging with short acquisitiontime and high spatial and temporal resolution Further technologicdevelopments (e.g., advances in miniaturization of the electronics

Figure 1.7 Apical two-chamber view of grating-lobe artifact (arrow) in

left ventricle.

3

Three-Dimensional Echocardiography

2

and in element interconnection technology) made it possible to insert

a full matrix array into the tip of a transesophageal probe and provide

transesophageal real-time volumetric imaging In addition to

trans-ducer engineering, improved computer processing power and the

availability of dedicated software packages for both online and

off-line analysis have allowed 3DE to become a practical clinical tool

COMPARISON BETWEEN 2DE AND 3DE

ULTRASOUND TRANSDUCERS

The backbone of the 3DE technology is the transducer A

conven-tional 2DE phased array transducer is composed of 128

piezoelec-tric elements, each elecpiezoelec-trically isolated and arranged in a single

row (Fig 2.1) Each ultrasound wave front is generated by firing

individual elements in a specific sequence with a delay in phase

with respect to the transmit initiation time Each element adds

and subtracts pulses to generate a single ultrasound wave with a

specific direction that constitutes a radially propagating scan line

(Fig 2.2) Because the piezoelectric elements area arranged in a

single row, the ultrasound beam can be steered in two dimensions:vertical (axial) and lateral (azimuthal) Resolution in thez axis (ele-vation) is fixed by the thickness of the tomographic slice, which inturn is related to the vertical dimension of piezoelectric elements(seeFigure 2.1)

Currently, 3DE matrix array transducers are composed of about

3000 individually connected and simultaneously active (fully pled) piezoelectric elements with operating frequencies rangingfrom 2 to 4 MHz and 5 to 7 MHz for transthoracic and transoeso-phageal transducers, respectively To steer the ultrasound beam

sam-in 3DE, a 3D array of piezoelectric elements must be present

in the probe; therefore, piezoelectric elements are arranged in

a rectangular grid (matrix configuration) within the transducer(seeFig 2.1,right) The electronically controlled phasic firing ofthe elements in that matrix generates a scan line that propagatesradially (y, or axial direction) and can be steered both laterally(x, or azimuthal direction) and in elevation (z, or vertical direction)

to acquire a volumetric pyramid of data (seeFig 2.1,right) Matrixarray probes can also provide real-time multiple simultaneous 2D

Figure 2.1 Two- and three-dimensional transducers Schematic drawing showing the differences between 2D (left panel) and 3D (right panel) transducers.

PZEelements

T4

T5

System timedelays

Signalalignment

SummedRFdata

PZEelements

Figure 2.2 Two-dimensional beamforming Schematic drawing of beamforming using a conventional 2D phased array transducer During sion (A), focused beams of ultrasound are produced by pulsing each piezoelectric element with precalculated time delays (i.e., phasing) During recep- tion (B), signals from piezoelectric elements are delayed to create isophase signals that will be summed coherently.

transmis-views, at high frame rate, oriented in predefined or user-selected

plane orientations (Fig 2.3) The main technological breakthrough

that allowed manufacturers to develop fully sampled matrix

trans-ducers has been the miniaturization of electronics Individual

elec-trical connections can now be set for every piezoelectric element,

which can be independently controlled, both in transmission and in

reception

Beamforming is a technique used to process signals so that

directionally or spatially selected signals can be sent or received

from sensor arrays In 2DE, all the electronic components for

beam-forming (high-voltage transmitters, low-noise receivers,

analog-to-digital converter, digital controllers, digital delay lines) are in

the system and consume a lot of power (around 100 W and

1500 cm2 of personal computer [PC] electronics board area) If

the same beamforming approach was applied to matrix array

trans-ducers used in 3DE, it would require around 4 kW power

consump-tion and a huge PC board area to accommodate all the needed

electronics To reduce both power consumption and the size of

the connecting cable, several miniaturized circuit boards are

incor-porated into the transducer, so that partial beamforming can occur

in the probe (Fig 2.4) This unique circuit design results in an active

probe, which allows microbeamforming of the signal with low

power consumption (<1 W) and does not require connecting everypiezoelectric element to the ultrasound machine The 3000 channelcircuit boards within the transducer control the fine steering bydelaying and summing signals within subsections of the matrix,known aspatches (seeFig 2.4) This microbeamforming allowsthe number of digital channels in the cable connecting the probe

to the ultrasound system to be decreased from 3000 to 128 to

256 If 3000 channels were required, the cable would be too heavyfor practical use Therefore the cable used with 3D probes is thesame size as that used for a 2D probe Coarse steering is controlled

by the ultrasound system where the analog-to-digital conversionoccurs using digital delay lines (seeFig 2.4)

However, the amount of heat produced by the electronics insidethe probe is directly proportional to the mechanical index used dur-ing imaging; therefore the engineering of active 3DE transducersshould include thermal management

Finally, new and advanced crystal manufacturing processesallows production of single crystal materials with homogeneoussolid-state technology and unique piezoelectric properties Thesenew transducers produce less heat by increasing the efficiency ofthe transduction process, which improves the conversion of trans-mitted power into ultrasound energy and of received ultrasound

Figure 2.3 Multiplane acquisition using the matrix array transducer Biplane and triplane acquisitions with matrix array transducers.

128-256 channeldigital beamforming

DelayDelayDelay

Delay

DelayDelay

DelayDelay

3000 channelmicrobeamformer(analog prebeamforming)

Patch

Figure 2.4 Three-dimensional

beam-forming Beamforming with 3D matrix

array transducers has been divided into

processes that occur in two locations:

the transducer and the ultrasound (US)

machine At the transducer level,

inter-connection technology and integrated

analog circuits (delay units) control

trans-mit and receive signals using different

subsections of the matrix (patches) to

perform analog prebeamforming and fine

steering Signals from each patch are

summed to decrease the number of

digi-tal lines in the coaxial cable that connects

the transducer to the ultrasound system.

The number of channels is reduced from

3000 to the conventional 128 to 256 At

the ultrasound machine level,

analog-to-digital (A/D) convertors amplify, filter,

and digitize the elements signals, which

are then focused (coarse steering) using

digital delay (Delay) circuitry and summed

together to form the received signal from a

desired object.

5

Three-Dimensional Echocardiography

2

energy into electrical power Increased transduction efficiency

together with a wider bandwidth results in increased ultrasound

penetration and resolution, which both improves image quality

and reduces artifacts Thus power consumption is decreased, and

Doppler sensitivity is increased

Further developments in transducer technology have resulted in

a reduced transducer footprint, improved side-lobe suppression,

increased sensitivity and penetration, and the implementation of

harmonic capabilities that can be used for both gray-scale and

con-trast imaging The most recent generation of matrix transducers are

significantly smaller than the previous ones, and the quality of 2DE

and 3DE imaging has improved significantly, allowing a single

transducer to acquire both 2DE and 3DE studies, and record the

whole left ventricular cavity in a single beat

3D ECHOCARDIOGRAPHY PHYSICS

3DE is an ultrasound technique, and the physical limitation of the

constant speed of ultrasound frequencies in human tissues

(approx-imately 1540 m/sec in myocardial tissue and blood) cannot be

over-come The speed of sound in human tissues divided by the distance

a single pulse has to travel out and back (determined by the image

depth) results in the maximum number of pulses that can be fired

each second without producing interferences Based on the

acquired pyramidal angular width and the desired beam spacing

in each dimension (spatial resolution), this number is related to

the volume per second that can be imaged (temporal resolution)

Therefore, similar to 2DE imaging, there is an inverse relationship

between volume rate (temporal resolution), acquisition volume

size, and the number of scan lines (spatial resolution) that can be

achieved in 3DE Any increase in one of these factors will cause

a decrease in the other two

The relationship between volume rate, number of parallel

receive beams, sector width, depth, and line density can be

described by the following equation:

Volume rate =

2 × (volume width/lateral resolution)2 × Volume depth

1,540 × No of parallel receive beams

Therefore the volume rate can be adjusted to the specific needs by

either changing the volume width or depth The 3D system allows

the user to control the lateral resolution by changing the density of

the scan lines in the pyramidal sector too However, a decrease in

spatial resolution also affects the contrast of the image Volume rate

can also be increased by increasing the number of parallel receive

beams, but in this way the signal-to-noise ratio and the image

qual-ity will be affected

To put all this in perspective, let us assume that we want to

image depth up to 16 cm and acquire a pyramidal volume of

60
60 degrees Because the speed of sound is approximately

1540 m/sec, and each pulse has to propagate 16 cm
2 (to goout and back to the transducer), 1540/0.32 = 4812 pulses may befired per second without getting interference between the pulses.Assuming that 1-degree beam spacing in both X and Z dimensions

is a sufficient spatial resolution, we would need 3600 beams(60
60) to spatially resolve the 60
60 degrees pyramidal vol-ume As a result, we will get a temporal resolution (volume rate)

of 4812/3600 = 1.3 Hz, which is practically useless in clinicalechocardiography

The previous example shows that the fixed speed of sound inbody tissues is a major challenge to the development of 3DEimaging Manufacturers have developed several techniques such

as parallel receive beamforming, multibeat imaging, and real-timezoom acquisition to cope with this challenge; but in practice this isusually achieved by selecting the appropriate acquisition modalityfor different imaging purposes (see “Image Acquisition andDisplay”)

Parallel receive beamforming or multiline acquisition is a nique where the system transmits one wide beam and receives mul-tiple narrow beams in parallel In this way the volume rate(temporal resolution) is increased by a factor equal to the number

tech-of the received beams Each beamformer focuses along a slightlydifferent direction that was insonated by the broad transmit pulse

As an example, to obtain a pyramidal volume that is 90
90degrees and 16 cm deep at 25 volumes per second (vps), the systemneeds to receive 200,000 lines/sec The emission rate is around

5000 pulses per second, so the system should receive 42 beams

in parallel for each emitted pulse However, increasing the number

of parallel beams to increase temporal resolution leads to increases

in size, cost, and power consumption of the beamforming ics, and decreases in the signal-to-noise ratio and contrast resolu-tion With this technique of processing the received data,multiple scan lines can be sampled in the amount of time a conven-tional scanner would take for a single line However, this occurs atthe expense of reduced signal strength and resolution, as thereceived beams are steered increasingly farther away from the cen-ter of the transmitted beam (Fig 2.5)

electron-Another technique to increase the pyramidal volume and tain the volume rate (or the reverse, e.g., maintain volume rateand increase the pyramidal volume) is multibeat acquisition Withthis technique, a number of electrocardiographic (ECG)-gated sub-volumes acquired from consecutive cardiac cycles are stitchedtogether to build up the final pyramidal volume (Fig 2.6) Multi-beat acquisition will be effective only if the different subvolumeshave constant position and size; therefore any transducer move-ment, cardiac translation motion due to respiration, and change

main-in cardiac cycle length will create subvolume misalignment andstitching artifacts (Fig 2.7)

Figure 2.5 Parallel receive beamforming Schematic representation of the parallel receive or multiline beamforming technique receiving 16 (left) or 64 (center) beams for each transmit pulse (dashed red line) The right panel shows the degradation of the power and resolution of the signal (from red [maximal] to bright yellow [minimal]) from the parallel receiving beams steered farther away from the center of the transmit beam.

Finally, the image quality that can be obtained from a 3DE dataset of the cardiac structures will be affected by the point spread func-tion of the system The point spread function describes the imagingsystem response to a point input A point input, represented as a sin-gle pixel in the “ideal” image, will be reproduced as something otherthan a single pixel in the “real” image (Fig 2.8) The degree of

C

Figure 2.6 Multibeat acquisition 2D (A) and 3D (B) volume-rendered imaging of the mitral valve from the ventricular perspective The latter has been obtained from a four-beat full-volume acquisition illustrated in C The four pyramidal subvolumes (the colors show the relationships among the pyra- midal subvolumes, the ECG beats, and the way the 3D data set has been built up in the lower part of the figure).

Figure 2.7 Stitching artifacts Volume-rendered image displayed with

respiratory gating artifacts The blue lines highlight the misalignment of

the pyramidal subvolumes.

Object

Image

PSFFigure 2.8 Point spread function A, Graphical representation of the extent of degradation (blur) of a point passing through a optical system.

B, Effect of the point spread function on the final image of a circular object.

7

Three-Dimensional Echocardiography

2

spreading (blurring) of any point object varies according to the

dimension employed In current 3DE systems, the approximate

spreads will be 0.5 mm in the axial(y) dimension, 2.5 mm in the

lat-eral(x) dimension, and 3 mm in the elevation (z) dimension As a

result, we will obtain the best images (less blurring, or distortion)

when using the axial dimension, and the worst images (more

blur-ring) when we use the elevation dimension

These concepts have an immediate practical application when

choosing the best approach to image a cardiac structure According

to the point spread function of 3DE, the best results are expected by

using the parasternal approach, because structures are primarily

imaged in the axial and lateral dimensions Conversely, the worst

results are expected with an apical approach, which mostly uses

the lateral and elevation dimensions (Fig 2.9)

IMAGE ACQUISITION AND DISPLAY

Currently, 3D data set acquisition can be easily integrated with

standard echocardiographic examination by either switching 2D

and 3D probes, or, with the newest all-in-one probes, by alternating

their 2D and 3D modalities The latter probes can also provide

single-beat, full-volume acquisition, and real-time 3D color

Doppler imaging

At present, three methods for 3D data set acquisition are

avail-able: (1) multiplane imaging, (2) real-time (live) 3D imaging, and

(3) multibeat ECG-gated imaging

In the multiplane mode, multiple simultaneous 2D views can be

acquired at high frame rate using predefined or user-selected plane

orientations; and the views may be displayed using the split screen

option (seeFig 2.3) The first view on the left is usually the

refer-ence plane that is oriented by adjusting the probe position, whereas

the other views are derived from the reference image by simply

tilt-ing and/or rotattilt-ing the imagtilt-ing planes Multiplane imagtilt-ing is a

real-time acquisition, and secondary imaging planes can only be

selected during acquisition Doppler color flow can be

superim-posed on 2D images, and in some systems both tissue Doppler

and speckle tracking analysis can be performed Although strictly

not a 3D acquisition, this imaging mode is useful in situations

where assessment of multiple views from the same cardiac cycle

is useful (e.g., atrial fibrillation or other arrhythmias, stress

echo-cardiography, interventricular dyssynchrony)

In real-time mode, a pyramidal 3D volumetric data set is

obtained from each cardiac cycle and visualized live, as during

2D scanning As the data set is updated in real time, image

orientation and plane can be changed by rotating or tilting theprobe Analysis can be done with limited postprocessing, and thedata set can be rotated (independent of the transducer position)

to view the heart from different orientations Heart dynamics areshown realistically, with instantaneous, online, volume-renderedreconstruction It allows fast acquisition of dynamic pyramidal datastructures from a single acoustic view that can encompass the entireheart without the need of reference systems, ECGs, or respiratorygating Real-time imaging saves time in both data acquisition andanalysis Although this acquisition mode eliminates rhythm distur-bances and respiratory motion limitations, it still suffers from rel-atively poor temporal and spatial resolution Real-time imaging can

be acquired in the following modes:

1 Live 3D: Once the desired cardiac structure has been imaged in2DE it can be converted to a 3D image by pressing the properbutton in the control panel The 3D system automaticallyswitches to a narrow sector acquisition (approximately

30
60 degrees pyramidal volume) to preserve spatial and poral resolution The size of the pyramidal volume can beincreased to visualize larger structures, but both scan line den-sity (spatial resolution) and volume rate (temporal resolution)will drop 3D live imaging mode is used to:

tem-a Guide full-volume acquisition

b Visualize small structures (aortic valve, masses, etc.)

c Record short-lived events (e.g., bubble passage)

d Acquire data in patients with irregular rhythm or dyspneathat prevents full-volume acquisition

e Monitor interventional procedures

2 Live 3D color: Color flow can be superimposed on a live 3Ddata set to visualize blood flow in real time Temporal resolution

is usually very low

3 3D zoom: This imaging mode is an extension of live 3D andallows a focused real-time view of a structure of interest A cropbox is placed on a 2D single plane or multiplane image to allowthe operator to adjust lateral and elevation width to include thestructure of interest in the final data set; then the system auto-matically crops the adjacent structures to provide a real-timedisplay of that structure with high spatial and temporal resolu-tion The drawback of the 3D zoom mode is that the operatorloses the relationship between the structure of interest and thesurrounding structures It is mainly used during transesophagealstudies for detailed anatomic analysis of the structure ofinterest

From parasternal approach

From apical approachFigure 2.9 Impact of the acquisition window on the spatial resolution of a 3D data set Multislice display of a left ventricular data set acquired from parasternal and apical approaches in the same patient The short axis views have been taken at the same level from both data sets The higher spatial resolution of the data set acquired using the parasternal approach is readily appreciated.

4 Full-volume: The full-volume mode has the largest acquisition

volume possible (usually 90
90 degrees) Real-time (or

single-beat) full-volume acquisition is affected by low spatial and

tem-poral resolution, and it is used for quantification of cardiac

chambers when multibeat ECG-gated acquisition is not possible

(e.g., irregular cardiac rhythm, patient unable to cooperate with

breath-holding)

In contrast to real-time/live 3D imaging, multibeat acquisition

requires sequential acquisitions of narrow smaller volumes

obtained from several consecutive ECG-gated heart cycles (from

two to six) that are subsequently stitched together to create a single

volumetric data set (seeFig 2.6) Unlike live 3D imaging, the data

set cannot be changed by manipulating the probe imaging after it is

acquired; and analysis requires offline slicing, rotating, and

crop-ping the acquired data set It provides large data sets with high

tem-poral and spatial resolution that can be used for quantitating cardiac

chamber size and function or assessing spatial relationships among

cardiac structures However, this 3D imaging mode has the

disad-vantage of the ECG-gating because the images are acquired over

several cardiac cycles, and the final data set is visible only after

the last cardiac cycle has been acquired It is anear real-time

imag-ing, and it is prone to artifacts due to patient or respiratory motion

or irregular cardiac rhythms Multibeat imaging can be acquired

with or without color flow mapping, and usually more cardiac

cycles are required for 3D color data sets

3D data sets can be sectioned in several planes and rotated to

visualize the cardiac structure of interest from any desired

perspec-tive, regardless of its orientation and position within the heart This

allows the operator to easily obtain unique visualizations that may

be difficult or impossible to achieve using conventional 2DE (e.g.,

en face views of the tricuspid valve or cardiac defects) Three main

actions are undertaken by the operator to obtain the desired view

from a 3D volumetric data set: cropping, slicing, and rotating

Sim-ilarly to what the anatomists or surgeons do to expose an anatomic

structure within a 3DE data set, the operator should remove the rounding chamber walls This process of virtually removing theirrelevant neighboring tissue is called cropping (Fig 2.10), andcan be performed either during or after acquisition In contrast with2D images, displaying a cropped image also requires data set rota-tion (seeFig 2.10), and the definition of the viewing perspective(i.e., because the same 3D structure can be visualized en face, eitherfrom above or below, and from any desired angle) Slicing refers to

sur-a virtusur-al cutting of the 3D dsur-atsur-a set into one or more (up to twelve)2D (tomographic) gray-scale images (Fig 2.11) Finally, regardless

of its acquisition window, a cropped or a sliced image should

be displayed according to the anatomic orientation of the heartwithin the human body and this is usually obtained by rotatingthe selected images

Acquisition of volumetric images generates the technical problem

of rendering the depth perception on a flat 2D monitor 3D imagescan be visualized using three display modalities (Fig 2.12):volume rendering, surface rendering, and tomographic slices

In the volume rendering modality, various color maps areapplied to convey the depth perception to the observer Generally,lighter shades (e.g., bronze; seeFigure 2.6) are used for structurescloser to the observer, whereas darker shades (e.g., blue; see

Fig 2.6) are used for deeper structures Surface rendering modalitydisplays the 3D surface of cardiac structures, identified either bymanual tracing or by using automated border detection algorithms

on multiple 2D cross-sectional images of the structure or cavity ofinterest This stereoscopic approach is useful for assessing theshape and for better appreciating geometry and dynamic functionduring the cardiac cycle Finally, the pyramidal data set can beautomatically sliced in several tomographic views and simulta-neously displayed (seeFig 2.11) Cut planes can be orthogonal,parallel, or free (any given plane orientation), selected as desired

by the echocardiographer for obtaining optimized cross sections

of the heart to answer specific clinical questions and to performaccurate and reproducible measurements

Pyramidal 3D data set(uncropped)

Parallel cropping atmitral valve level

9

Three-Dimensional Echocardiography

3

Volume rendering Surface rendering

3D Full volume

Multislice

Figure 2.12 Three-dimensional data set display From the same pyramidal three-dimensional data set, the left ventricle can be visualized using ferent display modalities: volume rendering, to visualize morphology and spatial relationships among adjacent structures; surface-rendering, for quan- titative purposes; and multislice (multiple 2D tomographic views extracted automatically from a single 3D data set) for morphologic and functional analysis at different regional levels.

3 Doppler Principles

Frederick W Kremkau, PhD

TheDoppler effect is a change in frequency caused by motion of a

sound source, receiver, or reflector If a reflector is moving toward

the source and receiver (the ultrasound transducer in our context),

the received echo has a higher frequency than would be

experi-enced without the motion Conversely, if the motion is away

(reced-ing), the received echo has a lower frequency The amount of

increase or decrease in the frequency depends on the speed of

reflector motion, the angle between the sound propagation direction

and the motion direction, and the frequency of the wave emitted by

the source Thechange in frequency (difference between emitted

and received frequencies) caused by the reflector motion is called

the Doppler shift frequency or, more commonly, the Doppler shift

(fD) The Doppler shift is equal to the received frequency (fR) minus

the source frequency (fT) For approaching reflectors (e.g., blood

cells), the Doppler shift is positive; that is, the received frequency

is greater than the source frequency For a receding reflector,

Doppler shift is negative; that is, the received frequency is less than

the source frequency The proportional relationship between the

Doppler shift and the reflector speed (v) is given by the Doppler

equation:

wherec is the speed of sound in tissue, and θ is the Doppler angle, the

angle between the sound beam direction and the flow direction Take,

for example, a source frequency of 5 MHz, an approaching flow

speed of 50 cm/sec, a propagation (sound) speed of 1.54 mm/μsec

and a Doppler angle of zero degrees (cos=1) The blood is

approach-ing the source, so the received frequency is greater than the source

frequency, with a positive Doppler shift of 0.0032 MHz, or

3.2 kHz For flow away from the transducer, the Doppler shift is

3.2 kHz The Doppler shift is what the instruments described in this

chapter detect The Doppler shift is proportional to the blood flow

speed, which is why the Doppler effect is so useful in medical

diag-nosis The Doppler equation is solved to yield calculated flow speed

information Doppler shifts can also be used to detect and present the

motion of myocardial tissue as described inChapter 4

If the direction of sound propagation is parallel to the flow

direc-tion, the maximum Doppler shift is obtained If the angle between

these two directions (Fig 3.1) is nonzero (nonparallel), Doppler

shifts will be lower Half the original Doppler shift occurs at an angle

of 60 degrees, and no Doppler shift occurs at 90 degrees As shown in

the Doppler equation, the Doppler shift depends on the cosine of the

Doppler angle The angle is estimated by orienting an indicator line

on the anatomic display so that it is parallel to the presumed direction

of flow This is a subjective operation performed by the instrument

operator In much echocardiographic work, the Doppler angle is 20

degrees or less, and angle incorporation can be ignored In this case,

the instrument assumes an angle of zero, and the error in calculated

flow speed is an underestimation of 6% or less

COLOR DOPPLER DISPLAYS

Doppler operation presents information on the presence, direction,

speed, and character of blood flow and on the presence, direction,

and speed of tissue motion This information is presented in

audi-ble, color Doppler, and spectral Doppler forms Color Doppler

imaging presents two-dimensional, cross-sectional, real-time blood

flow or tissue motion information along with two-dimensional,

cross-sectional, gray-scale anatomic imaging Two-dimensionalreal-time presentations of flow information allow the observer toreadily locate regions of abnormal flow for further evaluation usingspectral analysis The direction of flow is appreciated readily, anddisturbed or turbulent flow is presented dramatically in two-dimensional form Color Doppler operation presents anatomicinformation in the conventional gray-scale form and also rapidlydetects Doppler shift frequencies at several locations along eachscan line, presenting them in color at appropriate locations in thecross-sectional image The color map decodes the color assign-ments In the map in the upper right corner of Figure 3.2, red

7060504030

20

Flow

10

Figure 3.1 Doppler shift decreases as Doppler angle increases.

Figure 3.2 Apical view in color Doppler form The red region shows upward flow toward the apex and the transducer The blue region shows regurgitant flow into the atrium.

11

and yellow represent increasingly positive Doppler shifts above the

black (zero Doppler shift) baseline, and blue and cyan represent

increasingly negative Doppler shifts below the baseline

SPECTRAL DOPPLER DISPLAYS

The termspectral relates to a spectrum, an array of the frequency

components of a wave, separated and arranged in order of

increas-ing frequency The termanalysis comes from a Greek word

mean-ing to “break up” or “take apart.” Thus spectral analysis is the

breaking up of the frequency components of a complex wave or

sig-nal and spreading them out in order of increasing frequency A

mathematical process called the fast Fourier transform (FFT) is

used to analyze the frequency spectrum of the Doppler signal

The spectral display shows the Doppler shift spectrum (converted

to flow speed by solving the Doppler equation) on the vertical axis

and time on the horizontal axis (Fig 3.3) A broad spectrum is

asso-ciated with turbulent flow, whereas a narrow spectrum is assoasso-ciated

with laminar flow Two types of spectral Doppler operation are

used for detection of flow in the heart: continuous wave (CW)

and pulsed wave (PW) CW operation detects Doppler-shifted

ech-oes in the relatively large region of overlap between the beams of

the transmitting and receiving elements of a transducer PW

oper-ation emits ultrasound pulses and receives echoes using a single

element transducer or an array Through range gating on reception,

pulsed wave Doppler selects information from a particular depth

along the beam, forming a small sample volume If the electronic

gate opens later, the sample volume moves deeper To use pulsed

wave Doppler effectively, it is combined with gray-scale

sonogra-phy so the anatomic location of the sample volume is known

Spec-tral Doppler operation provides continuous or pulsed voltages to

the transducer and converts echo voltages received from the

trans-ducer to audible and visible information corresponding to blood

flow CW operation detects flow that occurs anywhere within the

intersection of the transmitting and receiving beams of the dual

transducer assembly The sample volume is the region from which

Doppler-shifted echoes return and are presented audibly or

visually In this case, the sample volume is the overlapping region

of the transmitting and receiving beams Because the sample ume is large, CW Doppler systems can give complicated and con-fusing presentations if two or more motions or flows are included inthe sample volume Pulsed Doppler systems solve this problem bydetecting motion or flow at a selected depth with a relatively smallsample volume However, the large sample volume of a CW system

vol-is helpful when searching for a Doppler maximum to calculate sure drop across a valvular stenosis

pres-To eliminate clutter, which is the high-intensity, low-frequencyDoppler-shifted echoes caused by heart wall or cardiac valvemotion with pulsatile flow, a wall filter that rejects frequenciesbelow an adjustable value is used Sometimes called awall-thumpfilter, the filter rejects these strong echoes that otherwise wouldoverwhelm the weaker echoes from the blood These strong echoeshave low Doppler shift frequencies because the tissue structures donot move as fast as the blood does The upper limit of the filter isadjustable

Aliasing

A pulsed Doppler instrument does not detect the entire Dopplershift frequency as a CW instrument does, but rather it obtains sam-ples of the Doppler shift signal because the pulsed instrument is asampling system, with each pulse yielding a sample of the Dopplershift signal The samples are connected and smoothed (filtered) toyield the sampled waveform If the pulsing (sampling) rate is notsufficient, aliasing occurs Aliasing is the most common artifactencountered in Doppler ultrasound The wordalias comes fromthe Middle Englishells, Latin alius, and Greek allos, which mean

“other” or “otherwise.” Contemporary meanings for the wordinclude (as an adverb) “otherwise called” or “otherwise knownas,” and (as a noun) “an assumed or additional name.” Aliasing

in its technical use indicates improper representation of informationthat has been sampled insufficiently An optical form of temporalaliasing occurs in motion pictures when wagon wheels appear torotate at various speeds and in reverse direction Similar visual

Figure 3.3 Color Doppler (upper) and spectral-Doppler (lower) presentations.

effects are observed when a fan is lighted with a strobe light.

Depending on the flashing rate of the strobe light, the fan may

appear stationary or rotating clockwise or counterclockwise at

var-ious speeds.Figure 3.4illustrates aliasing in spectral and color

dis-plays The Nyquist limit describes the minimum number of samples

required to prevent aliasing At least two samples per cycle of the

measured Doppler shift must be made for the image to present

cor-rectly For a complicated signal, such as a Doppler signal

contain-ing many frequencies, the samplcontain-ing rate should be twice that of the

highest frequency contained within the Doppler signal, so that at

least two samples are taken within this cycle To restate this rule,

if the highest Doppler shift frequency present in a signal exceeds

one half the sampling frequency (which is the pulse repetition

frequency), aliasing will occur There are two primary methodsfor dealing with aliasing Baseline shifting is a cut-and-pastemethod that moves the misplaced portions of the spectral displays

to their correct location (where they would be if aliasing did notoccur) Increasing the spectral display vertical scale increases thesampling rate to achieve the necessary Nyquist limit to avoid alias-ing In extreme cases, both methods are employed

Marek Belohlavek, MD, PhD, Tasneem Z : Naqvi, MD

PRINCIPLES OF TISSUE DOPPLER IMAGING

Since the initial efforts,1tissue Doppler imaging (TDI) has become

a clinical and investigative echocardiographic tool for real-time

quantitative measurements of tissue mechanics.2–4TDI is

princi-pally similar to flow Doppler imaging, but it is technologically

focused on lower motion tissue velocities (Fig 4.1).3TDI provides

tissue velocity spectra in a pulsed wave (PW) Doppler mode and

color-coded superimposed velocities in M-mode and B-mode.5

TDI is angle-dependent, and therefore the Doppler beam angle

should be corrected if the direction of the beam is not parallel to

the tissue motion As a rule, the incident beam angle should not

exceed 15 degrees, thus keeping the velocity underestimation at

4% or less.4Color TDI is accomplished by employing the

autocor-relation technique for obtaining multiple gated points of

color-coded velocity along each scan line and real-time superimposition

of these points over an M-mode or B-mode image (Fig 4.2).3

Tissue velocity spectra at any region of interest can be interrogated

in a PW Doppler mode from the color-coded B-mode image.5The

number of gated points along each scan line depends on pulse etition frequency The pulse repetition frequency and the number ofscan lines determine the resulting frame rate High frame rates(preferably more than 100 frames/sec and ideally at least 140frames/sec) of the current TDI systems are achieved by parallel pro-cessing of ultrasound signals returning along different scan lines.Reducing the depth and width of B-mode and Doppler sectorsand using a setting that favors temporal over spatial resolutionare also required.4Because PW Doppler measures peak velocities,whereas color TDI generates mean velocities, the values provided

rep-by PW Doppler can be 20% to 30% higher than those measured rep-bycolor TDI.2

Doppler signals from tissues are different from those produced byblood (seeFig 4.1) The backscatter amplitude of tissue signals isapproximately 100 times higher than that of blood flow signals;whereas typical tissue velocities of 4 to 15 cm/sec in a normal heartare lower by a factor of 10 as compared with velocities of blood flow(usually ranging from 40 to 150 cm/sec).6Imaging of tissue Doppler

Figure 3.4 A , Spectral Doppler display with aliasing The peak systolic portions of the signal are chopped off at the lower boundary and reappear at the upper boundary The peak value is buried and unrecoverable with baseline shifting Uncovering the correct presentation requires a scale increase in this case B, Transesophageal echocardiography color Doppler display with aliasing (red, orange, and yellow areas in the region of the mitral valve) The flow is downward from atrium to ventricle and should be blue (negative Doppler shifts) according to the map However, the blood accelerates as it passes through the mitral valve and the Doppler shifts exceed the negative Nyquist limit The color then jumps to the upper Nyquist limit, turning

to yellow and progressing down the map through orange to red Then the reverse sequence occurs as the blood decelerates into the ventricle The upward flow in the outflow tract correctly shows as positive shifts (red).

13

Tissue Doppler Imaging and Speckle Tracking Echocardiography

4

signals is achieved in an ultrasound system by (1) allowing lowvelocities by disengaging a high-pass filter used during blood flowimaging to block clutter signals from tissue or emphasizing lowvelocity high amplitude signals from tissue by using a low-pass filter;(2) eliminating weak blood flow signals by gain damping; and (3)using a proper color map during postprocessing to accommodatefor the lower velocity range of tissue motion.5,7

STRAIN RATE, STRAIN, AND DISPLACEMENTTDI is susceptible to translational motion and tethering of tissue.This disadvantage can be minimized by measuring local velocitygradients rather than individual velocities.2Strain rate (SR) or rate

of deformation (Fig 4.2) equals the velocity gradient calculated(Fig 4.3) as the difference of two instantaneous velocities (Vaand Vb) normalized for the distance (d) between the two velocitylocations (a) and (b) as follows2,8:

The unit of SR is s1or 1/s.9By convention, the shortening rate isrepresented by a negative value, whereas the lengthening rate has apositive value Although the accuracy of Vaand Vbvalues remainangle-dependent, the definition of SR implies that the sameamounts of translational or tethering velocities will cancel out bysubtraction of the Vaand Vbvalues

Motion velocity (Doppler frequency)

Preserved signal

Figure 4.1 Principle of separating Doppler signals returning from tissue

and blood Relatively low tissue velocities can be preserved or

empha-sized by disengaging a high-pass or using a low-pass velocity filter,

respectively Relatively high-amplitude tissue signals allow adjusting

the gain threshold to effectively filter out low-amplitude (blood) signals.

As a result, the relatively low-velocity high-amplitude tissue signals are

preserved (Modified from Sutherland GR, Bijnens B, McDicken WN

Tis-sue Doppler echocardiography: historical perspective and technological

considerations Echocardiography 1999;16:445-453, with permission.)

Spatial integration

Temporal

integration

Spatial derivation

Spatial integration

Spatial derivation

Temporal derivation

Temporal integration

Temporal derivation

Figure 4.2 Examples of two-dimensional displays of myocardial motion (velocity and displacement) and deformation (strain rate and strain) using the same data set The motion and deformation parameters are mathematically related as shown Tracings from three corresponding locations demon- strate instantaneous velocity, displacement, strain rate, and strain over the same cardiac cycle Peak systolic velocity and magnitude of displacement are higher near the cardiac base and lower near the cardiac apex, whereas strain rate and strain tracings do not present such spatial gradient Early (E 0)

and atrial (A 0)components of tissue velocity are marked (Modified with permission from A Stoylen Strain rate imaging http://folk.ntnu.no/stoylen/ strainrate/ Accessed February 28, 2014.)

Strain (S) is the amount of deformation (seeFig 4.2) relative to

a reference state9expressed as a fraction or percentage Assuming

very short time intervals (dt) between consecutive frames, S can be

obtained in TDI by integrating the instantaneous SR values from

the time point t0to t as8:

t

t

Tissue displacement (D), measured in millimeters or centimeters, is

the amount of position change (seeFig 4.2) that can be calculated

in TDI by temporal integration of velocity (V) as4:

t

t

Besides velocity, strain, strain rate, and displacement, additional

parameters include (1) acceleration and deceleration to further assess

left ventricular (LV) contraction and relaxation function2,7and (2)

time-to-peak systolic LV velocity or strain rate in various segments

to detect dyssynchrony of LV motion4 or determine postsystoliccontraction Postsystolic contraction may occur physiologically10

or in an ischemic or dyssynchronous LV.11SPECKLE TRACKING ECHOCARDIOGRAPHYSpeckle tracking echocardiography (STE) has emerged as an alter-native to TDI.12Speckles, natural acoustic markers that appear asbright and dark spots within the LV wall in a typical B-mode image,result from interactions (such as reflections, scattering, or interfer-ence) of an ultrasound beam with myocardial tissue.13 STEassumes that the acoustic markers move together with tissue and

do not change their pattern significantly in adjacent frames(Figure 4.4, A) A two-dimensional (2D) displacement vector isobtained by tracking the markers alongx and y directions in theconsecutive B-mode frames Then a 2D local velocity vector is cal-culated for each myocardial location (Fig 4.4,B).12

Frame rate is

Ultrasoundbeam

-5 s-1-25 cm/s

15

Tissue Doppler Imaging and Speckle Tracking Echocardiography

4

an important factor in STE A frame rate that is too high may not

yield enough speckle displacement for the tracking algorithm to

operate reliably A frame rate that is too low, on the other hand,

may lead to the loss of speckles because they may move out of

the plane of the subsequent frame Frame rates of 40 to 80

frames/sec have been used in 2D STE applications involving

nor-mal heart rates; higher frame rates may be required to track

myo-cardium in hearts with tachycardia.4 Three-dimensional speckle

tracking may be used to acquire complete spatial information about

myocardial deformation; however, relatively low spatial and

tem-poral resolutions and variances in results due to different

algo-rithms are the current limitations.4,14

Strain definition applicable to STE is a change in length between

two speckle locations from an initial length (L0) to a new length (L1)

normalized to L0.2,8,9Thus strain can be expressed as:

When deformation analysis is based on theinitial length L0, it is

referred to as the Lagrangian strain, whereas when deformation

is based on aninstantaneous status, then so-called Eulerian

(natu-ral) strain is measured,9,15such as by temporal integration of

instan-taneous strain rates in TDI STE can be applied to all cardiac

chambers, although the thin walls of the right ventricle and atria

may limit the speckle tracking accuracy.4Layer-specific analysis

of myocardial strains has been explored as a tool for identification

of nontransmural ischemia.16,17

Compared with TDI, STE measures tissue velocity irrespective

of the ultrasound beam angle However, STE is not completely

angle-independent because speckle appearance (and thus the ability

to track them) depends on spatial resolution, which is typically

bet-ter in axial than labet-teral direction, and depends on the angle of

inso-nation of myofibers B-mode scan quality is a critical factor in all

applications of STE, including three-dimensional strain analysis

Moreover, STE may have a limited ability to track fast or

short-lasting myocardial motion events.4

EVALUATIONS OF LV MECHANICS BY TDI AND STE

In the normal LV, the mean systolic shortening strains are

approximately15% to 20% and strain rates 1.2 to 2.0 sec-1

,although differences among myocardial segments or longitudinal, cir-

cumferential, and radial deformation components can be

consider-able.15,18–20Traces from three locations along the LV septum in

Figure 4.2reflect the increasingly higher systolic motion for both

velocity and displacement from the apical to basal myocardial

regions Deformation parameters (i.e., SR and S) do not show such

a spatial gradient STE supports global evaluations, such as

longitu-dinal strain measurements resulting from averaging local strains along

the LV wall.21Both TDI and STE allow analysis of peak systolic,

early (E0), and atrial (A0) components of myocardial velocity (see

Fig 4.2) LV rotation and twist (in degrees or radians) are also

mea-sures of global LV mechanics and reflect myocardial fiber orientation

changing from a right-handed helix in the subendocardium to a

left-handed helix in the subepicardium.22 Viewed from the apex,

LV apical rotation is counterclockwise and basal rotation is clockwise

during ejection.13LV twist or untwist is the difference in apical and

basal rotation in systole or diastole, respectively.10Apical LV rotation

is the dominant contributor to LV twisting motion.23 LV torsion,although often used interchangeably with the term twist, is defined

as a twist normalized to LV length and measured in degrees/cm orradians/m.22Evaluations of LV mechanics are affected by age, gen-der, heart rate, loading conditions, and the processing algorithm.4

5 Gorcsan J 3rd: Assessment of left ventricular systolic function using color-coded tissue Doppler echocardiography, Echocardiography 16:455–463, 1999.

6 Sutherland GR, Bijnens B, McDicken WN: Tissue Doppler echocardiography: historical perspective and technological considerations, Echocardiography 16:445–453, 1999.

7 Brodin LA: Tissue Doppler, a fundamental tool for parametric imaging, Clin siol Funct Imaging 24:147–155, 2004.

Phy-8 Gilman G, Khandheria BK, Hagen ME, et al: Strain rate and strain: a step-by-step approach to image and data acquisition, J Am Soc Echocardiogr 17:1011–1020, 2004.

9 D’Hooge J, Heimdal A, Jamal F, et al: Regional strain and strain rate ments by cardiac ultrasound: principles, implementation and limitations, Eur J Echocardiogr 1:154–170, 2000.

measure-10 Sengupta PP, Korinek J, Belohlavek M, et al: Left ventricular structure and tion: basic science for cardiac imaging, J Am Coll Cardiol 48:1988–2001, 2006.

func-11 Ring M, Persson H, Mejhert M, et al: Post-systolic motion in patients with heart failure–a marker of left ventricular dyssynchrony? Eur J Echocardiogr 8:352–359, 2007.

12 Leitman M, Lysyansky P, Sidenko S, et al: Two-dimensional strain-a novel ware for real-time quantitative echocardiographic assessment of myocardial func- tion, J Am Soc Echocardiogr 17:1021–1029, 2004.

soft-13 Helle-Valle T, Crosby J, Edvardsen T, et al: New noninvasive method for ment of left ventricular rotation: speckle tracking echocardiography, Circulation 112:3149–3156, 2005.

assess-14 Jasaityte R, Heyde B, D’Hooge J: Current state of three-dimensional myocardial strain estimation using echocardiography, J Am Soc Echocardiogr 26:15–28, 2013.

15 Edvardsen T, Gerber BL, Garot J, et al: Quantitative assessment of intrinsic regional myocardial deformation by Doppler strain rate echocardiography in humans: validation against three-dimensional tagged magnetic resonance imag- ing, Circulation 106:50–56, 2002.

16 Wang J, Urheim S, Korinek J, et al: Analysis of postsystolic myocardial ing work in selective myocardial layers during progressive myocardial ischemia, J

thicken-Am Soc Echocardiogr 19:1102–1111, 2006.

17 Kimura K, Takenaka K, Ebihara A, et al: Reproducibility and diagnostic accuracy

of three-layer speckle tracking echocardiography in a swine chronic ischemia model, Echocardiography 28:1148–1155, 2011.

18 Marwick TH, Leano RL, Brown J, et al: Myocardial strain measurement with dimensional speckle-tracking echocardiography: definition of normal range, JACC Cardiovasc Imaging 2:80–84, 2009.

2-19 Sun JP, Lee AP, Wu C, et al: Quantification of left ventricular regional myocardial function using two-dimensional speckle tracking echocardiography in healthy volunteers–a multi-center study, Int J Cardiol 167:495–501, 2013.

20 Yingchoncharoen T, Agarwal S, Popovic ZB, et al: Normal ranges of left ular strain: a meta-analysis, J Am Soc Echocardiogr 26:185–191, 2013.

ventric-21 Reisner SA, Lysyansky P, Agmon Y, et al: Global longitudinal strain: a novel index

of left ventricular systolic function, J Am Soc Echocardiogr 17:630–633, 2004.

22 Sengupta PP, Tajik AJ, Chandrasekaran K, et al: Twist mechanics of the left tricle: principles and application, JACC Cardiovasc Imaging 1:366–376, 2008.

ven-23 Opdahl A, Helle-Valle T, Remme EW, et al: Apical rotation by speckle tracking echocardiography: a simplified bedside index of left ventricular twist, J Am Soc Echocardiogr 21:1121–1128, 2008.