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Causes of Diastolic Dysfunction

Acknowledgment The authors acknowledge the contributions of Dr. Rebecca Lynn Baumann, who was the author of this chapter in the previous edition. Definitions Diastolic dysfunction can be defined as an abnormality in the ability of the left ventricle to fill at normal pressure. Diastolic dysfunction, unlike heart failure with preserved ejection fraction (HFpEF) or diastolic heart failure, is not a clinical diagnosis but rather refers to…

Clinical Recommendations for Echocardiography Laboratories for Assessment of Left Ventricular Diastolic Function and Filling Pressures

Many patients are referred to the echocardiography laboratory with complaints of dyspnea. These include patients with normal and depressed left ventricular (LV) ejection fraction (EF). It is important to determine whether symptoms in these patients have a cardiac cause or not because this can have therapeutic implications for decisions that include the use and titration of diuretics. Of note, many patients with LV systolic dysfunction have…

Echo Doppler Parameters of Diastolic Function

Diastolic heart failure, or heart failure with preserved ejection fraction (HFpEF), is not only a commonly encountered syndrome that accounts for approximately 50% of all heart failure but also a well-recognized contributor to clinical heart failure with increased morbidity and mortality similar to systolic heart failure. Diastole is a complex and dynamic phenomenon that is influenced by age, loading condition, heart rate, and peripheral vascular tone.…

Physiology of Diastole

Normal diastole consists of four time intervals: isovolumic relaxation time (IVRT), early diastolic filling (rapid filling or E phase), diastasis, and late diastolic filling (atrial kick or A phase). Left ventricular (LV) diastole conventionally begins with the closure of the aortic valve (AV), which ushers the drop in LV pressure. The time interval between AV closure and mitral valve (MV) opening is the isovolumic relaxation time…

Pulmonary Embolism

Acknowledgments The authors would like to acknowledge the contributions of Drs. Zhao, Rigolin, and Goldstein, who were the authors of this chapter in a previous edition. Pulmonary embolism (PE) is a common and often fatal disease. In the United States, more than 250,000 people are diagnosed with PE annually, and more than 60,000 die from the disease each year. However, PE is one of the most…

The Right Atrium

Acknowledgment The authors acknowledge the contributions of Dr. Nimrod Blank, who was a coauthor of this chapter in the previous edition. The right atrium (RA) is an important but often overlooked cardiac chamber. It is situated in the most anterolateral region of the heart, and it normally receives deoxygenated blood from the superior vena cava (SVC), inferior vena cava (IVC), and coronary sinus. The RA is…

Right Ventricular Hemodynamics

Acknowledgments The authors would like to thank Drs. Laurence G. Rudsky and Amr E. Abbas for their contributions to this chapter in the previous edition. Echocardiography is the primary clinical method for the noninvasive measurement of right heart hemodynamic parameters and is an indispensable tool for the initial assessment, diagnosis, longitudinal follow-up, and prognostication of patients with abnormal right heart function. Ohm’s law describes the relationship…

Assessment of Right Ventricular Systolic and Diastolic Function

The right ventricle (RV) plays a key role in the outcome of many disease states. RV dysfunction is associated with excess morbidity and mortality in patients with chronic left-sided heart failure (HF), acute myocardial infarction (MI), pulmonary embolism (PE), pulmonary arterial hypertension (PAH), and congenital heart disease. Despite this knowledge, a standardized approach toward the echocardiographic assessment of the RV was only developed and applied a…

Imaging the Right Heart: Limitations and Technical Considerations

The anatomy of the right ventricle (RV) creates significant technical challenges to an accurate echocardiographic assessment. Proper image acquisition is highly dependent on precise movements and angulations of the transducer as well as the volume and pressure states of the ventricle. Numerous measurements such as estimation of RV function, calculation of RV hemodynamics, and assessment of the right atrium (RA) rely on meticulous image procurement and…

The Physiologic Basis of Right Ventricular Echocardiography

The right ventricle (RV), which had been deemed the forgotten ventricle, is now recognized as a central player in cardiovascular function. Its physiology, shape, function, and coronary blood flow are complex and impose impediments to noninvasive imaging. This chapter reviews the physiology of the RV and describes echocardiographic, functional, and structural correlates. The RV was first described as more than a passive conduit in 1616 by…

Right Ventricular Anatomy

Acknowledgment The author thanks Dr. Scott D. Solomon for his contribution to the previous edition of this chapter. Historically, the echocardiographic assessment of diseases affecting the right ventricle (RV) has lagged behind that of the left ventricle (LV), despite knowledge demonstrating that diseases affecting the right side of the heart have been shown to have important clinical consequences. The geometry of the RV is very complex…

Myocardial Strain in Valvular Heart Disease

Acknowledgments Dr. Gorcsan was supported, in part, by research grants from Medtronic, EBR Systems, GE Medical Systems, and V-Wave Ltd. Myocardial strain measurement using speckle-tracking echocardiography (STE) has made major contributions to the care of patients with cardiac diseases. This chapter focuses on emerging applications specific to patients with valvular heart disease. Most of the recent studies on myocardial strain and valvular disease have been retrospective…

Regional Left Ventricular Systolic Function

Given its considerable diagnostic, prognostic, and therapeutic implications, the assessment of left ventricular (LV) regional systolic function forms an important part of any echocardiographic examination. Because coronary artery disease (CAD) is by far the commonest cause resulting in regional LV systolic dysfunction, the mere presence of regional wall motion abnormality (RWMA) usually confirms the presence of underlying CAD. Additionally, the distribution of RWMA helps in predicting…

Global Left Ventricular Systolic Function: Ejection Fraction Versus Strain

The assessment of global left ventricular (LV) systolic function is a cornerstone of risk evaluation and management in most cardiac diseases. The simplest and most widely used parameter for this purpose has been ejection fraction (EF) and regional wall motion analysis, but over the past decade, new parameters such as global longitudinal strain (GLS) have become available. Indications for Systolic Function Evaluation Echocardiography is appropriately indicated…

Technical Aspects of Contrast Echocardiography

In 2001, the American Society of Echocardiography (ASE) published a position paper that provided guidelines for sonographers performing contrast-enhanced echocardiographic studies. This chapter focuses on the sonographer’s role in four specific areas: (1) understanding of microbubble physics and ultrasound instrumentation, (2) recognition of indications for the use of contrast media, (3) need for establishment of intravenous (IV) access privileges, and (4) development of written policies for…

Use of Contrast in the Intensive Care Unit and Emergency Department

Contrast Use in the Intensive Care Unit Patients in the intensive care unit (ICU) setting have a variety of illnesses, and echocardiography can offer real-time information on cardiac function, hemodynamics, and, in certain patients, potential causes of their illnesses. Furthermore, because echocardiography is noninvasive, portable, and free of ionizing radiation, it is an ideal tool for ICU patient care. However, the ICU is an often hostile…

Applications of Ultrasound Contrast Agents

Echocardiography plays a critical role in the management of patients, especially in its ability to evaluate left ventricular (LV) global and regional function. Its clinical utility, however, may be affected by image quality. In approximately 10% to 15% of routine echocardiograms and up to 25% to 30% of studies performed in intensive care units, the endocardial border is not clearly defined. Ultrasound contrast agents have been…

Physical Properties of Microbubble Ultrasound Contrast Agents

Microbubble Contrast Agents A wide variety of ultrasound-enhancing agents (UEAs), or contrast agents, have been developed for use in diagnostic imaging. Agents that have been approved by regulatory agencies for routine diagnostic use in humans are composed of encapsulated microbubbles. Key considerations that have guided the design of these agents are that they must be safe, able to transit the pulmonary and systemic microcirculation unimpeded, and…

Ultrasound-Enhancing Agents

Currently Available Second-Generation Ultrasound Contrast Agents The 2018 American Society of Echocardiography Guidelines recommended changing the terminology of ultrasound contrast agents to ultrasound-enhancing agents (UEAs) for the purpose of distinguishing UEAs from traditional iodinated or magnetic resonance agents. The currently available UEAs in the United States are Optison (General Electric Healthcare), Lumason (Bracco Healthcare), and Definity (Lantheus Imaging). Lumason is the same as what is marketed…