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Diagnostic Echocardiography Laboratory: Structure, Standards, and Quality Improvement

Echocardiography has evolved dramatically, starting with initial M-mode and two-dimensional (2D) imaging in the 1970s and growing with the addition of spectral and color Doppler in the 1980s. Since then, the breadth and sophistication of echocardiography’s clinical applications, as detailed elsewhere in this textbook, have exploded and continue to evolve. To manage this growth, echocardiography laboratories must establish and maintain an appropriate environment of care encompassing…

Right Ventricular Anatomy and Function

Acknowledgments The authors wish to acknowledge Anjali Vaidya, MD, and James N. Kirkpatrick, MD, the authors of related chapters in previous editions of The Practice of Clinical Echocardiography. The right ventricle (RV) is a complex but critical structure for normal cardiovascular function. Descriptions of the role of the RV in normal cardiovascular physiology have evolved throughout history. Some of the earliest documented studies of cardiac anatomic…

Left Ventricular Diastolic Function

Left ventricular diastolic dysfunction (LVDD) plays a major role in the pathophysiology of heart failure (HF). From a practical perspective, LV diastolic function assessment is particularly useful when evaluating patients with dyspnea of suspected or known cardiac origin. In patients with dyspnea and preserved LV ejection fraction (EF), the identification of LVDD offers the pathophysiologic basis for diagnosing HF with preserved ejection fraction (HFpEF), which is…

Quantitative Analysis of Left Ventricular Anatomy and Systolic Function

Quantitative Analysis of LV Anatomy LV Size Linear Measurements The shape of the normal left ventricle (LV) corresponds to a prolate ellipsoid. Linear measurements of the LV therefore allow limited conclusions about its size and should not be used for determining its volume. Nevertheless, the diameter of the LV provides an estimation of LV size and may be useful in patients with limited echocardiographic windows, such…

Contrast Echocardiography

Contrast echocardiography describes an array of techniques that produce acoustic enhancement of the blood pool during cardiovascular ultrasound imaging in order to improve the accuracy of conventional echocardiography or to create new diagnostic capabilities. A broad definition of contrast echocardiography extends to the use of rapidly dissolving air bubbles formed from hand agitation of fluid, such as saline, for detection of right-to-left shunt physiology, a technique…

Principles of Myocardial Mechanics and Strain Imaging

In daily clinical practice, left ventricular (LV) function is commonly evaluated by two-dimensional (2D) echocardiography. The most widely used measure of global LV function is ejection fraction (EF), and regional function is evaluated by visual assessment of wall motion. LV global longitudinal strain (GLS), as measured by speckle tracking echocardiography (STE), was introduced as a more sensitive parameter than LVEF to detect mild systolic dysfunction. Measurement…

3D Echocardiographic Image Acquisition, Display, and Analysis

Three-dimensional (3D) echocardiography (3DE) is one of the most important innovations in the field of cardiovascular ultrasonography. To maximize the information obtained from a 3DE data set, image acquisition and analysis should be performed with a deep understanding of the underlying technical principles and using a systematic approach. Although there are differences among cardiovascular ultrasound equipment manufacturers with respect to terminology and technical performance, the underlying…

Case 1—Cardiology consult before noncardiac surgery for brain tumor

History A 72-year-old Caucasian woman presented with a recent onset of headaches and visual changes and was found to have two cerebral tumors with surrounding edema in the right parietal and occipital lobes on brain MRI. There was a history of colon adenocarcinoma surgery 4 years ago. Cardiology was consulted by neurosurgery for cardiac clearance for brain surgery due to two consecutive troponin levels of 37…

Case 1—a 72-year-old man with fatigue after mitral valve replacement

History A 72-year-old man status post pericardial mitral valve (MV) replacement for a flail mitral valve and severe mitral regurgitation, Cox maze procedure for paroxysmal atrial fibrillation, and left atrial appendage ligation 10 days ago, presented with symptoms of fatigue, pleuritic precordial chest pain, intermittent blurred vision, and possible facial droop. A brain MRI showed small new subacute cerebral infarcts, which appeared to have occurred perioperatively…

CHAPTER 11

Case 1—An 85-Year-Old Man With Remote Aortic Valve Replacement Presents With Dyspnea History An 85-year-old man presented with dyspnea on exertion, ankle swelling, and NYHA class II heart failure. He reported no orthopnea or paroxysmal nocturnal dyspnea. Patient had a bioprosthetic aortic valve (AV) implanted 15 years ago and was referred for “diastolic heart failure.” Physical examination There was a 3/6 crescendo-decrescendo systolic murmur at the…

CHAPTER 10

Case 1—62-Year-Old Man for General Medical Evaluation History A 62-year-old man presented for routine general medical evaluation. There was a history of mild exertional dyspnea and palpitations. His New York Heart Association class was class I. There was no abnormal heart rate or rhythm on Apple Watch 5 monitoring. Physical examination Physical examination undertaken by an outside cardiologist 4 months ago had revealed a “murmur.” Stress…

CHAPTER 9

Case 1—A 75-Year-Old Woman With Known Advanced Cardiomyopathy Presents to the Emergency Department With Recurrent Dyspnea History A 75-year-old woman presented to the emergency department with increasing weight gain and shortness of breath. She was known to have nonischemic cardiomyopathy with a very poor ejection fraction of 14% and was being evaluated by palliative care. She took extra doses of the diuretic bumetanide (Bumex) with increased…

CHAPTER 8

Case 1—A 72-Year-Old Man With Dysphagia, Dyspnea, and Ankle Edema History ■ Α 78-year-old man presented with worsening dysphagia, dyspnea, and ankle edema. ■ He had a history of coronary artery disease status post prior coronary artery stenting, congestive heart failure (CHF), ischemic cardiomyopathy requiring an implantable cardioverter defibrillator (ICD) and biventricular (Biv) pacemaker, hypertension, obstructive sleep apnea, and paroxysmal atrial fibrillation (AF). ■ Laboratory values:…

CHAPTER 7

Case 1—A 70-Year-Old Man With Postoperative Atrial Fibrillation History ■ Cardiology consultation was obtained for a 70-year-old man for atrial fibrillation (AF) after a second knee arthroplasty surgery during current admission. Patient was on coumadin, and it had been restarted postoperatively. ■ He had a history of AF perioperatively for knee arthroplasty 4 years ago. ■ Patient had undergone mechanical mitral valve replacement 9 years ago…

How to perform ultrasound of the heart and its arterial and venous connections

Patient positioning ■ Semi-recumbent position on the left side with the head elevated ■ Left arm under the head or the pillow ■ Right arm on the right side Operator positioning Right-handed operator: The operator sits on the patient’s right side with the transducer in the right hand and uses the left hand to operate the ultrasound system. Left-handed operator: The operator sits on the patient’s…

Cardiac vascular connections, anatomy, and ultrasound imaging: Major Blood Vessels Encountered During Routine Echocardiography

Aorta It arises from the left ventricle and is divided into the aortic root, tubular ascending aorta, aortic arch, descending thoracic aorta, and abdominal aorta ( Fig. 2.1 ). All these aortic segments are assessed during routine echocardiography. The tubular ascending aorta comprises of a proximal portion, from the sinotubular junction to the pulmonary artery level, and a distal portion, from the pulmonary artery to the…