Continuing Education Activity
Echocardiography is a widely performed procedure to diagnose cardiomyopathy, valvular heart disease, aorta, and pericardial disease. This activity reviews the importance of adult echocardiography and highlights the interprofessional team's role in performing this procedure.
Objectives:
Identify the indications for echocardiography.
Explain the anatomy of structures on the echocardiogram.
Review the clinical significance of echocardiography.
Summarize how employing an interprofessional team approach can improve patient outcomes when using echocardiography on appropriate patient populations.
Introduction
Echocardiography is a non-invasive diagnostic modality to examine the structure and function of the heart and great vessels. In 1950,the German scientist, Wolfe Dieter Keidel, utilize the transmitted ultrasonic wave technique to study the heart. However, he was not able able to create information regarding cardiac function.[1]
In 1953, Dr. Inge, the father of echocardiography and inventor of M-Mode, and Dr. Helmut Hertz established a commercial ultrasound machine to study the heart.[2] The development of echocardiography modalities such as M-Mode, A-mode, Doppler, transthoracic, transesophageal, contrast, stress echocardiography, and strain imaging took decades and helpedachieveprompt diagnoses of various cardiac illnesses.
Anatomy and Physiology
Transthoracic Echocardiography views and anatomy:[3]
Parasternal Long-axis View
Structures
Chambers identified in this view: left atrium, left ventricle, left ventricle outflow tract, aorta.
Valves identified in this view: mitral valve and aortic valve
This view helps in identifying regurgitant and stenotic jets of mitral and aortic valves.[4]See Image. ParasternalLongAxisView on TransthoracicEchocardiography.
Parasternal Short-axis View
Structures
Chambers identified in this view: left atrium, right atrium, right ventricle outflow tract, main pulmonary artery
Valves identified in this view: aortic valve, pulmonary valve, tricuspid valve
This view helps in identifying the tricuspid and pulmonary valve disease as well as patent ductus arteriosus.
Apical 4 Chamber View
Structures
Chambers identified in this view: left atrium, right atrium, left ventricle, and right ventricle
Valves identified in this view: mitral and tricuspid valve
This view helps identify the wall motion abnormalities of the inferior septal wall and anterolateral wall of the left ventricle, mitral, and tricuspid valve disease. See Image. Apical Four-ChamberView on Transthoracic Echocardiography.
Apical 5 Chamber View
Structures
Chambers identified in this view: left atrium, right atrium, left ventricle, left ventricle outflow tract, right ventricle, and aorta
Valves identified in this view: mitral valve, tricuspid valve, and aortic valve
This view provides additional information on the Left ventricle outflow tract, aortic valve, and aortic root compared to the four-chamber view.
Apical 2 Chamber View
Structures
Chambers identified in this view: left atrium and left ventricle
Valves identified in this view: mitral valve
This view helps identify the wall motion abnormalities of the inferior wall and anterior wall of the left ventricle and mitral valve disease. See Image. Apical Two-ChamberView on Transthoracic Echocardiography.
Apical Parasternal long-axis View
Structures
Chambers identified in this view: left atrium, left ventricle, left ventricle outflow tract, aorta.
Valves identified in this view: mitral valve and aortic valve
This view helps identify the wall motion abnormalities of the anterior septal wall and the inferolateral wall of the left ventricle. In this view, mitral valve and aortic valve disease areidentifiable. See Image. Apical Parasternal Long-Axis View on Transthoracic Echocardiography.
See AlsoNew Releases on Netflix & Top 10 Movies & Series This Week: November 22, 2024The ELSO Maastricht Treaty for ECLS Nomenclature: abbreviations for cannulation configuration in extracorporeal life support - a position paper of the Extracorporeal Life Support OrganizationSprunki Incredibox: Free Online Game Mods
Subcostal Coronal View
Structures
Chambers identified in this view: left atrium, right atrium, left ventricle, and right ventricle
Valves identified in this view: mitral and tricuspid valve
This view helps in diagnosing interatrial septal defect, pericardial effusion, and cardiac tamponade.
Subcostal Saggital view
Structures
Chambers identified in this view: right atrium, inferior vena cava, hepatic vein, and descending aorta
This view helps in assessing the fluid status of the patient.
Suprasternal Noch View
Structures
Chambers identified in this view: left atrium, aortic arch, brachiocephalic artery, left common carotid artery, left subclavian artery, right pulmonary artery.
This view helps in diagnosing aorta diseases such as aortic dissection and coarctation of the aorta. In this view, congenital heart defect, patent ductus arteriosus can be identified.
Indications
Appropriate Use And Indication Criteria for Echocardiography According to ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/ SCCT/SCMR 2011[5][6]
Symptoms related to cardiac diseases such as chest pain, shortness of breath, syncope, palpitations, transient ischemic attack, stroke, and peripheral embolic event
Previous diagnostic tests such as cardiac enzymes, electrocardiogram, and chest X-ray indicating cardiac disease
Premature ventricular contraction ( Frequent or exercise-induced)
Arrhythmias such as Atrial fibrillation, Atrioventricular node re-entry tachycardia, and Ventricular tachycardia (sustained or non-sustained)
Evaluation of right ventricular function (fractional area change, tricuspid annular plane systolic excursion(TAPSE), Right index of myocardial performance (RIMP), and pulmonary artery pressure in a patient with suspected pulmonary artery hypertension
Routine follow-up of patients as surveillance (>1 year) for diagnosed pulmonary artery hypertension patients without a change in symptoms or physical examination
To guide management in patients diagnosed with pulmonary artery hypertension and change in cardiac symptoms or physical examination
Patient in shock with an uncertain or suspected cardiac cause
For evaluation pf patient with a suspicion of myocardial infarction either with chest pain or diagnostic tests such as cardiac enzymes and electrocardiogram indicating of myocardial infarction
For diagnosis of valvular heart disease
To guide management in patients diagnosed with valvular heart disease and change in cardiac symptoms or physical examination.
Patients with suspicion of hypertensive heart disease, prosthetic valve dysfunction, infective endocarditis, heart failure, congenital heart disease, cardiac mass, pericardial disease, aortic aneurysm, aortic dissection, or cardiovascular source of embolus
Indication for Transesophageal Echocardiography
Transthoracic echo nondiagnostic due to patient characteristics
To guide percutaneous noncoronary cardiac interventions such as closure device placement, radiofrequency ablation, and percutaneous valve procedures.
To rule out cardiovascular sources such as embolus in patients with no other non-cardiac cause.
To provide help in the decision-making of cardioversion, anticoagulation, and ablation in atrial flutter or atrial fibrillation.
To diagnose infective endocarditis in patients with moderate-high pretest probability.
Indication for Stress Echocardiography
Patients with intermediate and high pre-test probability for coronary artery disease
Patients with a possible acute coronary syndrome (electrocardiogram: no ischemic changes or with LBBB or electronically paced ventricular rhythm, low-risk TIMI score with either borderline or minimally elevated troponin, High-risk TIMI score with negative troponin)
Contraindications
According to ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/ SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography, Inappropriate Transthoracic Echocardiography Indications
Patients with asymptomatic sinus bradycardia
Patients with infrequent Atrial premature contractions or Ventricular premature contractions
Patients with presyncope and no other evidence of cardiac disease
Evaluation of left ventricle function for Pre-operative screening in patients without symptoms or signs of cardiac disease
Routine follow-up of patients as surveillance (<1 year) for diagnosed pulmonary artery hypertension patients without a change in symptoms or physical examination
Routine follow-up of patients as surveillance in patients with a previous history of pulmonary embolism with normal right ventricular function and pulmonary artery systolic pressure
Absolute Contraindications Of Transesophageal Echocardiography
History of esophageal stricture, perforation, tumor, laceration, and diverticulum
History of upper gastrointestinal bleeding
Severe atlantoaxial joint disorder
Conditions that prevent neck flexion
Inappropriate Transesophageal Echocardiography Indications
Routine use of transesophageal echocardiography in patients in whom decision regarding diagnosis and management already resolved by transthoracic echocardiography
To diagnose infective endocarditis in patients with low pretest probability.
To rule out cardiovascular source as embolus in patients with an obvious cardiac cause.
Patients with atrial fibrillation or atrial flutter in whom the decision to anticoagulant already made
Conditions In Which Stress Echocardiography Are Inappropriate
Patients with low pre-test probability for coronary artery disease
Patients with definite acute coronary syndrome
Equipment
Equipment Requirement for Transthoracic Echocardiography[7]
Echocardiography machine
Transducer
Contrast agent
Equipment Requirement for Transesophageal Echocardiography[8]
Echocardiography machine
Transesophageal Transducer
Medication for Sedation
Transesophageal bite block
Intravenous cannula for medications
For the bubble study, requirements are agitated saline, Three way stop cock, two 10 ml syringes, Extension tube connector)
Gel to lubricate Transesophageal probe
Topic anesthetic such as lidocaine to numb the pharynx
Equipment Requirement for Stress Echocardiography
Echocardiography machine
Exercise stress test machine
Cardiac monitor to look for vitals
Medications (such as dobutamine and atropine) to give stress in patients who can not perform an exercise stress test and medications ( such as Beta-blockers and calcium channel blockers) to reverse the effect of dobutamine and atropine
Personnel
Cardiologist
Echo technician
Technique or Treatment
For transthoracic echocardiography, the patient should lie in the left lateral position.
Complications
The complications from transthoracic echocardiography and stress echocardiography are infrequent.
Transesophageal Echocardiography[9][10]
Gastrointestinal bleeding
Esophageal perforation
Pharyngeal hematoma
Aspiration
Laryngospasm
Arrhythmia
Toxic methemoglobinemia
Stress Echocardiography[11][12]
Myocardial infarction
Arrhythmia
Coronary spasm
Hypertension or hypotension secondary to medication
Clinical Significance
Transthoracic echocardiography is a non-invasive test, low-cost, widely available, a first-line diagnostic test to evaluate cardiac disease and function. It not only helps to diagnose cardiac disease but also provides useful information to guide therapy.
Transesophageal Echocardiography: It is an invasive test done in the condition in which transthoracic echo is inconclusive or need further information on disease such as infective endocarditis. The esophagus's proximity to the heart and absence of intervening structures such as the lung make the Transesophageal echo ideal for examining various important structures.
Stress Echocardiography: The inclusion of imaging in routine stress testing increase both sensitivity and specificity of the test to diagnose coronary artery disease. Stress echocardiography post-myocardial infarction help in risk stratification, location, and extent of coronary artery disease. Stress echocardiography can also be used to risk-stratify patients before non-cardiac surgery as resting echo does not provide essential prognostic information.
Enhancing Healthcare Team Outcomes
To perform echocardiography requires an interprofessional team that includes a cardiologist and an echo technician. It is vital to take a proper historyand to perform a physical examination pre-procedure to determine the indication of the procedure. Communication between echo technicians and the cardiologist is essential, especially when there is a discrepancy in results.
Figure
Parasternal Long-Axis View on Transthoracic Echocardiography. Contributed by G Adnan, MD
Figure
Apical Four-Chamber View on Transthoracic Echocardiography. Contributed by G Adnan, MD
Figure
Apical Two-Chamber View on Transthoracic Echocardiography. Contributed by G Adnan, MD
Figure
Apical Parasternal Long-Axis View on Transthoracic Echocardiography. Contributed by G Adnan, MD
References
- 1.
Nixdorff U. The inaugurator of transmitted echocardiography: Prof. Dr Wolf-Dieter Keidel. Eur J Echocardiogr. 2009 Jan;10(1):48-9. [PubMed: 18922817]
- 2.
Acierno LJ, Worrell LT. Inge Edler: father of echocardiography. Clin Cardiol. 2002 Apr;25(4):197-9. [PMC free article: PMC6654569] [PubMed: 12000080]
- 3.
Mitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, Horton K, Ogunyankin KO, Palma RA, Velazquez EJ. Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2019 Jan;32(1):1-64. [PubMed: 30282592]
- 4.
Thomas JD. Doppler echocardiographic assessment of valvar regurgitation. Heart. 2002 Dec;88(6):651-7. [PMC free article: PMC1767478] [PubMed: 12433911]
- 5.
Rao G, Sajnani N, Kusnetzky LL, Main ML. Appropriate use of transthoracic echocardiography. Am J Cardiol. 2010 Jun 01;105(11):1640-2. [PubMed: 20494676]
- 6.
American College of Cardiology Foundation Appropriate Use Criteria Task Force. American Society of Echocardiography. American Heart Association. American Society of Nuclear Cardiology. Heart Failure Society of America. Heart Rhythm Society. Society for Cardiovascular Angiography and Interventions. Society of Critical Care Medicine. Society of Cardiovascular Computed Tomography. Society for Cardiovascular Magnetic Resonance. American College of Chest Physicians. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Parker Ward R, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr. 2011 Mar;24(3):229-67. [PubMed: 21338862]
- 7.
Hillis GS, Bloomfield P. Basic transthoracic echocardiography. BMJ. 2005 Jun 18;330(7505):1432-6. [PMC free article: PMC558382] [PubMed: 15961816]
- 8.
Prabhu M, Raju D, Pauli H. Transesophageal echocardiography: instrumentation and system controls. Ann Card Anaesth. 2012 Apr-Jun;15(2):144-55. [PubMed: 22508208]
- 9.
Côté G, Denault A. Transesophageal echocardiography-related complications. Can J Anaesth. 2008 Sep;55(9):622-47. [PubMed: 18840593]
- 10.
Min JK, Spencer KT, Furlong KT, DeCara JM, Sugeng L, Ward RP, Lang RM. Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations. J Am Soc Echocardiogr. 2005 Sep;18(9):925-9. [PubMed: 16153515]
- 11.
Hirano Y, Yamamoto T, Uehara H, Nakamura H, Wufuer M, Yamada S, Ikawa H, Ishikawa K. [Complications of stress echocardiography]. J Cardiol. 2001 Aug;38(2):73-80. [PubMed: 11525112]
- 12.
Mertes H, Sawada SG, Ryan T, Segar DS, Kovacs R, Foltz J, Feigenbaum H. Symptoms, adverse effects, and complications associated with dobutamine stress echocardiography. Experience in 1118 patients. Circulation. 1993 Jul;88(1):15-9. [PubMed: 8319327]
Disclosure: Ghufran Adnan declares no relevant financial relationships with ineligible companies.
Disclosure: Muhammad Nasir Rahman declares no relevant financial relationships with ineligible companies.
