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Long-Term Consequences and Prognosis After Myocardial Infarction

Introduction Substantial changes in cardiac structure can occur in the months to years following a completed myocardial infarct (MI), particularly if the culprit coronary artery supplied a large territory or flow was not rapidly restored. These changes may be clinically silent as they evolve, but with time can lead to extensive morbidity and mortality, including increased risk of developing heart failure and sudden cardiac death (SCD).…

Mechanical Complications of Myocardial Infarction

Introduction There is a short list of structural complications of which every cardiologist and sonographer must be aware that may arise in the subacute period after myocardial infarct (MI), that, within the first week ( Box 19.1 ). These are caused by necrosis of the heart muscle, and are frequently lethal if not caught early enough and repaired. The mechanical complications are: acute mitral regurgitation (MR),…

Acute Myocardial Infarction

Introduction Acute myocardial infarction (MI), the classic “heart attack,” is caused by the sudden loss of blood flow and oxygenation to the heart muscle due to complete occlusion of a coronary artery. The risk factors, clinical presentation, and serial changes in electrocardiogram (ECG) and serologic markers as myocardium is damaged are well known. For the physician and technologist, echocardiography often plays a critical role in the…

Assessment of the Atria

Introduction With each cardiac cycle, the left and right atria act as reservoirs, conduits, and pumps for blood traveling from the pulmonary and systemic veins into the ventricles. Normally functioning atria are compliant, with the ability to accommodate dynamic changes in intravascular volume without pathologic increases in pressure and are active pumps with the ability to enhance ventricular filling and cardiac output. Atrial structure and function…

Assessment of Right Ventricular Structure and Function

Introduction The assessment of right ventricular (RV) structure and function is one of the most critical roles of echocardiography, often impacting the diagnosis, management, and prognosis of patients with suspected cardiovascular disease. Historically, the echocardiographic assessment of diseases affecting the RV has lagged behind that of the left ventricle, despite knowledge demonstrating that diseases affecting the right heart have been shown to have the same clinical…

Left Ventricular Diastolic Function

Introduction Echocardiography plays a central role in the assessment of left ventricular (LV) diastolic function, which is often a challenging task for the clinician. Normal diastolic function allows for the LV to sufficiently fill and to generate the necessary stroke volume without exceeding certain pressure limits during filling. Diastolic dysfunction primarily results from increased resistance to ventricular filling, leading to an upward and leftward shift of…

Assessment of Left Ventricular Systolic Function

Introduction A major goal of the echocardiographic examination is the assessment of left ventricular (LV) structure and systolic function. This plays a critically important role in the diagnosis, risk evaluation, and management of patients with suspected or established cardiovascular disease. The left ventricle can be assessed qualitatively and quantitatively to define any alterations in cardiac size and geometry by using comprehensive measurements ( Fig. 14.1 ).…

Echo On-Call: Echocardiographic Emergencies

Introduction Echocardiography can be used appropriately to diagnose and triage emergent situations. The life-threatening pathologies in which real-time assessment by echocardiography can be critical include pericardial tamponade, aortic dissection, acute myocardial infarction (MI), acute pulmonary embolus (PE), and cardiac trauma. These conditions may cause severe chest pain, dyspnea with hypoxia, hypotension, and ultimately cardiogenic and respiratory shock. Even in cases where the primary cause of a…

Utilizing Contrast Echocardiography in Practice

Introduction Contrast echocardiography describes a set of specialized cardiovascular ultrasound techniques that rely on the administration of acoustically active contrast agents to complement standard imaging and Doppler echocardiography. Although there are many different types of acoustically active ultrasound contrast agents, those that are approved for clinical use are composed of gas-filled microbubbles encapsulated within a stabilizing exterior shell composed of surfactant materials, albumin, or biocompatible polymers…

Optimization of the Patient and Equipment

Introduction Optimal performance of the comprehensive two-dimensional (2D) transthoracic echocardiography (TTE) examination depends on the interaction between the operator (sonographer and/or physician), instrument (ultrasound system), and patient ( Fig. 11.1 ). This chapter will focus on techniques for optimizing acquisition that relate to the patient and ultrasound system, including optimizing the patient and transducer positions as well as using maneuvers and machine settings to optimize the…

Three-Dimensional Echocardiography: Image Acquisition

Introduction In the modern echocardiography laboratory, three-dimensional transthoracic echocardiography (3D-TTE) complements the standard two-dimensional transthoracic echocardiographic (2D-TTE) examination. 3D-TTE adds value, improves workflow, and substantially improves accuracy in the quantification of cardiac chambers by avoiding errors inherent in the geometric assumptions made in 2D-TTE ( Figs. 10.1 and 10.2 , and Video 10.1 ). 3D TTE provides a more accurate assessment of cardiac morphology and pathology,…

The Transthoracic Examination, View by View

Introduction This chapter presents the views acquired during the normal two-dimensional (2D) adult comprehensive transthoracic echocardiography (TTE) examination. These views are based on the standards recommended by the American Society of Echocardiography (see Chapter 8 ). Optimal image acquisition is a prerequisite for optimal interpretation and reporting of the adult transthoracic echocardiogram by the echocardiographer/cardiologist expert. This involves competency in cardiac sonographer skills and training, as…

Principles of Transthoracic Imaging Acquisition : The Standard Adult Transthoracic Echocardiographic Examination

Introduction In the adult two-dimensional (2D) transthoracic echocardiographic (TTE) examination, a standard series of cross-sectional anatomical views are recommended by the American Society of Echocardiography (ASE). Each echocardiographic view is described using three aspects of the examination, namely (1) the transducer positioned at a specified anatomical “window” on or near the thorax, (2) the cardiac scan plane transected by the transducer beam, and (3) the anatomical…

Understanding Imaging Artifacts

Introduction Imaging artifacts encompass patterns in the image that seem to suggest the presence of structures that are in reality not present. They may in fact relate to both the appearance of nonexistent structures, as well as the concealing of existing structures. Artifacts are mostly caused by physical interactions between the imaged tissue and ultrasound itself that are more complex than assumed by the ultrasound system;…

Principles and Practical Aspects of Strain Echocardiography

Introduction Assessment of regional and global ventricular function has long relied on visual assessment. However, this approach is subjective and variable leading to significant interobserver variability in interpretation. The heart is a mechanical organ and undergoes cyclic deformation in systole and diastole. This cyclic deformation can be measured and for decades was restricted to those undergoing open-heart surgery when metal beads were sown onto particular locations…

Principles of Three-Dimensional Ultrasound

Introduction Since 1974, when the first three-dimensional echocardiography (3DE) images of the heart were obtained by Dekker and colleagues, 3DE technology has greatly evolved. The development of the real-time volumetric acquisition technique, along with significant technological advances in computer and transducer technologies, have significantly improved the image quality and the practical feasibility of 3DE, allowing its implementation in clinical practice. 3DE data sets can be acquired…

Principles of Transesophageal Echocardiography

Introduction Transesophageal echocardiography (TEE) is an additional and complementary method of obtaining ultrasound images of the heart and surrounding structures. A flexible TEE probe is introduced, via the mouth, into the esophagus of the patient. The tip of the TEE probe contains a miniaturized phased array transducer capable of producing imaging planes in a full 180-degree spectrum (multiplane imaging; Fig. 4.1A ). TEE has all the…

Principles of Contrast Echocardiography

Introduction Contrast echocardiography is a broad term used to describe an array of approaches that can be used to improve and expand diagnostic capabilities by acoustic enhancement of the blood pool during cardiac ultrasound imaging. Ultrasound contrast agents are generally composed of gas-filled encapsulated microparticles, usually microbubbles that are 1–5 μm in diameter, or nanoparticles. The most common clinical application of contrast echocardiography has been to…

M-Mode Imaging

Introduction M-mode echocardiography provides superior temporal resolution, and therefore subtle changes are more readily appreciated with m-mode than with two-dimensional or three-dimensional methods. M-mode methods may include more precise measurement of cardiac chambers (provided they are obtained on-axis), independent motion of valvular vegetations, early closure or early opening of valve structures with respect to timing in the cardiac cycle ( Fig. 2.1 ), identification of prosthetic…

Physical Principles of Ultrasound and Generation of Images

Introduction Ultrasound imaging is ubiquitous in medical practice and is used to image all regions of the body, including soft tissues, blood vessels, and muscles. The machines used for ultrasound imaging range from small hand-held ultrasound devices no bigger than a smartphone to more elaborate and complex systems capable of advanced imaging techniques such as three-dimensional (3D) imaging. Although imaging of the heart and great vessels…