9/1/24, 9:35 AM Normal Module | Pediatric Echocardiography

Normal Module   (/c

Introduction to Basic Echo Doppler and Normal Cardiac Anatomy

Intro to Echocardiography Ultrasound Basics Physics of Doppler Types of Doppler Bernoulli Equation

Introduction to Echocardiography

Important Milestones in the Development of Echocardiography

Lazzaro Spallanzani (1794)
Studied bats’ use of ultrasound for navigation

Jean Daniel Colladon (1826)

Physicist used underwater church bell to calculate speed of sound

Christian Doppler (1845)

Theory of Doppler effect

Pierre and Jacques Curie (1880)

Discovered Piezo-Electric Effect

Paul Langevin (1915)

Physicist invented hydrophone to detect icebergs

Karl Dussik (1942)

Neurologist and first physician to use ultrasound (brain tumors)

The Development of Echocardiography

A and B mode echocardiography (Hertz and Edler, 1953)

M-mode echocardiography (early 1970s)

2-dimensional echocardiography (late 1970s)

Doppler echocardiography (1980s)

Pulse, continuous and color Doppler

2-Dimensional (2D) Echocardiography: non invasive assessment of intracardiac anatomy

Available for fetal, neonatal, pediatric and adult patients
Used to assess intracardiac anatomy for the presence of pathology
Quantification of valve, chamber and vessel sizes
Quantitative assessment of left ventricular function
Systolic Function
M-mode (fractional shortening)
2D volumetric assessment
Simpson's biplane
Bullet method
Diastolic function
Tissue Doppler
Mitral E/A and E/E' ratios
Pulmonary vein Ar to mitral A wave ratios

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Ultrasound Basics

What is Ultrasound?
A mechanical, longitudinal wave produced by passing electric current through a piezoelectric crystal
Requires a medium for transmission
Frequency exceeds the upper limit of human hearing (human hearing: 20-20,000 Hz)
Diagnostic ultrasound frequency range: 2.5–14 MHz
Ultrasound is free from radiation making it safe to use in fetuses, infants and children

Definition/Terminology
Frequency: The number of cycles that occur during a particular duration of time. In ultrasound, described as cycles per second (also known at Hertz)
Wavelength: The distance traveled by sound in one cycle or distance between two identical points in a wave cycle
Period: The time required to complete a single cycle
Amplitude: The magnitude of the pressure changes, i.e. the difference between the pressure peaks and nadirs (strength of the wave)
Compression: area of high density
Rarefication: area of low density
velocity = λ × ƒ
v= velocity (constant for a given medium)
ƒ= frequency (measured in hertz also known as Hz)
λ = wavelengh

Frequency
Frequency refers to the number of cycles of compressions and rarefactions in a sound wave per second, with one cycle per second being 1 hertz.

Wavelength
Distance traveled by sound in one cycle, or the distance between two identical points in the wave cycle.
Inversely proportional to the frequency.
Smaller wavelength = higher frequency = higher resolution = decreased penetration.
This can be an important factor when choosing an echo probe to image a particular patient

Higher frequency probes (10–12 MHz)

Poor penetration
High resolution of structures closer to the probe
Ideal for superficial structures or small infants

Lower frequency probes (2-7 MHz)

Better penetration
Lower resolution
Ideal for deeper structures and better for older children

Sound Propagation
Sound waves are comprised of
Compression (high air pressure)
Compression refers to an area of high density
Rarefaction (low air pressure)
Rarefaction refers to area of low density
Propagation velocity of sound is constant for a given medium and is dependent on the compressibility and density of the medium
Vs = λ × ƒ

Velocity of Sound in Various Materials

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Velocity of Sound
Material (m/s)

Air 330

Fat 1450

Water 1480

Human Soft Tissue (chest wall/heart) 1540

Brain 1540

Liver 1550

Kidney 1560

Blood 1570

Muscle 1580

Lens of eye 1620

Skull Bone 4080

Ultrasound Production
Local tissue compression/decompression

Propagates away from piezoelectric crystal in ultrasound probe at 1540 m/s in soft tissue
Rate of compression/decompression determines frequency, typically 2.5–10 MHz

Piezoelectric Crystals
Produce sound waves when electrically stimulated
Produce electrical signals when sound waves received
These electrical signals are converted into images

Ultrasound Propagation

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Incident

Reflected

Refracted

Absorption: Absorption is the most common form of attenuation. Absorption occurs as sound travels through soft tissue, the particles that transmit
the waves vibrate and cause friction with subsequent loss of sound energy in the form of heat. In soft tissue, sound intensity decreases exponentially
with depth.
Refraction: Refraction describes reflection in which the sound wave hits the boundary of two tissues at an oblique angle. The reflections generated do
not return directly back to the transducer. The angle of refraction is dependent on two things; the angle that the sound wave strikes the boundary
between the two tissues and the difference in their propagation velocities. If the propagation velocity is greater in the first medium, refraction occurs
towards the center, or perpendicular. If the velocity is greater in the second medium, refraction occurs away from the originating beam. In this
instance, sound is not reflected directly back to the transducer and the image being depicted may not be clear, or potentially altered.
Reflection: Reflection is categorized as specular or diffuse. Specular reflections represent large, smooth surfaces (i.e.- bone) where the sound wave is
reflected back in a single direction. The greater the acoustic impedance between the two tissue surfaces, the greater the reflection and hence the
brighter the echo will appear on ultrasound. Conversely, soft tissue is a diffuse reflector because adjoining cells create an uneven surface causing
reflections to return in various directions in relation to the transmitted beam. However, because of the numerous surfaces, sound is able to get back to
the transducer in a relatively uniform manner.

Dependent on:

Incident angle: 90 degrees maximizes reflection

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Optimal for imaging of 2D structures
Conversely, Doppler requires interrogation of structures parallel (between 0-20 degrees) to flow (see Doppler section below)
Density: Dense materials reflect more
Frequency: Higher frequency leads to higher absorption

Physics of Doppler

Christian Doppler (1803–1853)

Doppler Effect
First described by Austrian physicist Christian Doppler in 1842

When acoustic source moves relative to observer, frequencies of transmitted and observed waves are different
Effective tool to measure tissue velocities

Why is it relevant?
Ultrasound is transmitted into a vessel and the sound that is reflected from the blood is detected.
Blood is moving, therefore the sound undergoes a frequency (Doppler) shift.

Principles of Doppler
Beam of ultrasound hitting a moving object will be reflected back with a:

Longer wavelength if the object is moving away

Shorter wavelength if the object is moving towards

The faster the object of interest is moving the larger the Doppler shift.

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Image reference: https://theglobalsoundproject.tumblr.com

Doppler Equation
−2v cos θFt
Fp = c
Fp =
Frequency shift
Ft =
transmit frequency
θ=
angle between direction wave propagation and tissue motion
c=
velocity of sound in soft tissue (1530 m/s)

Doppler Shift with Sound Waves

Affected by:

Movement of ultrasound transmitter

Movement of reflector
Movement/properties of medium

Angle of incidence:

If not at 0 degrees, error in measurement

Acceptable limits of error are theta < 20 degrees (<6% error)
If interrogating a vascular structure by Doppler, ideal to be as parallel to flow as possible (between 0-20 degrees) to avoid error in measurement

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Principles of Doppler

2×ft ×V ×cosθ
Δf = ft − fr = C

Shift maxed for flows parallel to Doppler beam

V =
velocity of flow
ft =
transmit frequency
fr =
return frequency
C=
light constant
θ=
angle between U/S beam and blood column
At 0°:
cosθ = 1
At 90°:
cosθ = 0

Ideal angle of interrogation should be close to 0°, but acceptable if less than 20 degrees

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Effect of Doppler Angle

Effect of the Doppler angle in the sonogram. (A) higher-frequency Doppler signal is obtained if the beam is aligned more to the direction of flow. In the
diagram, beam (A) is more aligned than (B) and produces higher-frequency Doppler signals. The beam/flow angle at (C) is almost 90° and there is a very
poor Doppler signal. The flow at (D) is away from the beam and there is a negative signal.

Types of Doppler

Types of Doppler Ultrasound

Pulse Wave
Allows for sampling of velocity at a specific location of interest, but limited at higher velocities
High pulse repetition frequency (PRF)
Continuous Wave
Allows sampling of highest peak velocity along the line of interrogation
Lose ability to define exact location of specific velocities as sampling all velocities along line of interrogation
Color Doppler
Measures blood flow velocities
Assesses flow into or within vessels or chambers
Identifies regions of turbulent flow which may reflect stenosis
Tissue Doppler
Measures myocardial tissue velocities
Surrogate for the assessment of diastolic function and can be blunted in the setting of diastolic dysfunction

Clinical Use of Doppler Echocardiography

Pulse and Continuous Wave Doppler

Calculates mean and peak intracardiac gradients

Valvar (e.g., pulmonary stenosis, aortic stenosis, mitral stenosis)
Defects (ASD, VSD, PDA)
Estimate RV and pulmonary artery pressures

Color Doppler

Measures blood flow velocities

Demonstrates normal laminar flow in unobstructed vessels and valves
Demonstrates flow turbulence in narrowed vessels or across stenotic valves
Can be used to quantify and assess mechanism of valve regurgitation

Tissue Doppler

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Detects myocardial tissue velocities
Most commonly used for left ventricular lateral wall, interventricular septum and right ventricular free wall
Decreased in diastolic dysfunction

Pulse and Continuous Wave Doppler

For PW and CW Doppler:

X axis is Time
Y axis is Velocity
Moving toward is above the 0 line
Moving away is below the 0 line

Tips for Optimizing Pulse Doppler

Minimize angle of incidence
Use low frequency transducer
Shift baseline away from direction of flow
Use shallowest depth setting
Narrow interrogation sector to maximize frame rate
Set to high PRF

Pulse Repetition Frequency (PRF)

The PRF is the number of pulses (send and listen cycles) of ultrasound sent out by the transducer per second.
Also known as sampling frequency
It is dependent on:
Velocity of sound
Depth of tissue being interrogated
The deeper the tissue being examined, the longer the transducer has to wait for echoes to come back, hence a lower PRF.
High PRF
Probe emits 2nd signal prior to receiving first
If still get aliasing consider CW Doppler
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Nyquist Limit
Highest detectable velocity
It is equal to ½ PRF (pulse repetition frequency)
Exceeding this limit creates aliasing
Doppler signal appears to "wrap around"
Unable to accurately quantify true maximum velocity in this setting

Exceeding the Nyquist Limit: Aliasing

Aliasing
The inability to detect large Doppler shift is known as aliasing.
If velocity of scattering object is large and shift between subsequent acquisitions > ½ wavelength
PW Doppler ineffective at differentiating velocities
Methods to limit aliasing
Shallower depth
Continuous wave Doppler
Lower frequency transducer
Increase scale
Move baseline up or down
Down (if Doppler signal of interest is above baseline)
Up (if Doppler signal of interest is below baseline)
Increase PRF
Compromise must be made between velocity resolution and maximal detectable velocity

Pulse Wave Doppler

US signals sent at regular intervals (PRF) along ultrasound line
Based on frequency of reflected signals off RBCs, velocity signal is obtained
Range resolution
Move sample volume and localize velocity to specific region
Velocity determined only at point of interest or “sample gate”
Limited velocities PW can accurately measure
Higher velocities cause aliasing (if Doppler shift exceeds ½ PRF)

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Pulse wave Doppler across pulmonary valve

Two horizontal lines represent the sample gate

Doppler waveform has hollowed out appearance
Low velocity

Continuous Wave Doppler

One piezoelectric crystal transmits continuous wave of mixed frequency
Second crystal records continuously reflected signals
Sampling rate is infinite
Can measure high velocity signals
Useful for measuring peak velocities
Unable to localize velocity along beam signal
All velocities within scan line contribute to reflected signal and displayed on spectrogram leading to range ambiguity
Beware of measuring wrong signal
Velocities close to transducer contribute more than those further away

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Continuous wave Doppler across a VSD

No range gating (denoted by single circle or single horizontal line in spectral Doppler)
All velocities along scan line sampled
Doppler signal is well filled in
High velocity

Color Doppler
Uses multiple pulse wave signals to assess multiple sample volumes
Codes mean velocities at each sample gate
Real time image of blood flow
Color flow measures local spectrum of velocities
Blood flow is color coded
Red: towards transducer
Blue: away from transducer
Filter is applied to remove slow moving structures (cardiac walls)
Good for rapidly providing a gestalt of laminar versus disturbed flows and direction of flow in a real time image
It is important to adjust the nyquist limit depending on structure being interrogated
Setting a nyquist limit too low is larger vasculature with higher velocities (i.e.- aorta) may result in the false appearance of turbulent/disturbed
flow patterns
Need to decrease nyquist limit to assess flow within smaller vessels with lower velocities (i.e.- pulmonary veins and coronary arteries)

Color Doppler

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Blue moving away from the transducer

Red moving toward the transducer

Allows sampling of larger area

Width and depth of color jet
Direction of color jet
Detect multiple jets
Limited temporal resolution
Narrow width of interrogation to improve frame rate

Tissue Doppler Imaging

Can be performed in pulse wave and color modes.
Measures peak myocardial velocities
Angle dependent measurement
Used in apical four chamber view to access long-axis ventricular motion
Longitudinally oriented endocardial fibers are most parallel to the ultrasound beam in the apical views.
Mitral annular motion is a good surrogate measure of overall longitudinal left ventricular (LV) contraction and relaxation.
Provides assessment of diastolic function
Less load dependent than standard Doppler techniques.
Sa: Systolic myocardial motion
Ea: Velocity of early myocardial relaxation as the mitral annulus ascends during early rapid LV filling.
Aa: Atrial contraction

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Tissue Doppler imaging (TDI) of the ventricular septum

Bernoulli Equation

Daniel Bernoulli (1700–1782)

P1 − P2 = 4(V22 − V12 )

As fluid passes through an obstruction total drop in pressure due to:

Convective acceleration
Conversion to kinetic energy
Energy loss
Friction of fluid against wall (viscous losses)
From acceleration of fluid

Fluid acceleration, viscosity, and

V1
ignored in simplified equation

EXCEPTION: V1 cannot be ignored in the setting of multiple areas of obstruction in series

Modified Bernoulli Equation

Pressure gradient = 4V 2

V = peak velocity

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Spectral Doppler of Tricuspid Regurgitation (TR)

Estimate of RVP/PA Pressures

Pressure gradient = RVP– RAP

RVP = RAP + pressure gradient

RVP = 5 mmHg (assumed normal RA pressure) + 25 mmHg

RVP = 30 mmHg

TR jet can also be used to estimate the systolic pulmonary arterial pressure in an anatomically normal heart without right sided obstructive lesions
Pulmonary regurgitation spectral Doppler tracing can be used to estimate PA end diastolic and mean PA pressures

Modified Bernoulli Equation Applications

RVSP = 4(TR)2 + RAp

RVSP = SBP– 4(VSD)2

PA EDP = 4(PR)2 + RAp

LVSP = 4(MR)2 + LAp

Key

RVSP Right ventricular systolic pressure

LVSP Left ventricular systolic pressure

PA EDP Pulmonary artery end diastolic pressure

SBP Systolic blood pressure

TR Tricuspid regurgitation peak velocity

MR Mitral regurgitation peak velocity

PR Pulmonary regurgitation peak end diastolic velocity

VSD Peak spectral Doppler velocity across VSD

RAp Right atrial pressure

LAp Left atrial pressure

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Cardiac Morphology: The Cardiac Chambers

Cardiac chambers are identified in terms of their internal morphology and not in terms of other cardiac structures or by their spatial relationships

Important to use the most constant component to distinguish the identity of a chamber and not to use variable features

Right Atrium

Anteriorly located

Broad based triangular atrial appendage

Septum secundum

Receives the IVC, SVC and coronary sinus

Extensive pectinate muscles extend outside appendage towards tricuspid valve

Left Atrium

Posteriorly located

Long and narrow finger-like posterior atrial appendage

Flap of fossa ovalis (septum primum)

Receives pulmonary veins (majority of time, however, this can vary in the setting of anomalous pulmonary venous drainage)

Pectinate muscles confined to the left atrial appendage

Right Ventricle

Thin walled

Tripartite configuration

Coarse trabeculations (particularly towards the apex)

Presence of a moderator band (band of muscle that runs from the septum to the lateral wall of the right ventricle)

Trileaflet atrioventricular valve (tricuspid valve)

Lower more apically positioned septal leaflet attachment of tricuspid valve

Tricuspid valve chordae insert to the interventricular septum and indistinct papillary muscles (septophilic)

Fibrous discontinuity between tricuspid and pulmonary valve (subpulmonary conus)

Left Ventricle

Smooth walled

Bullet shaped configuration

Fine trabeculations

No moderater band

Bileaflet atrioventricular valve (mitral valve)

Higher, more basally positioned mitral valve

Fibrous continuity with mitral and aortic valve (absent conus)

The mitral valve attaches to two distinct papillary muscles which insert to the LV free wall

Absence of mitral valve attachments to the interventricular septum (septophobic)

Lesions & Views = Visited

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Normal Echocardiogram (/course/normal/echocardiogram)

 Parasternal long axis LVOT Ao mitral (/course/normal/echocardiogram/plax-lvot-ao-mitral-p1a)

 Parasternal long axis tricuspid valve (/course/normal/echocardiogram/plax-tricuspid-p1b)

 Parasternal long axis pulmonary valve (/course/normal/echocardiogram/plax-pv-p1c)

 Parasternal long axis Ao root and STJ (/course/normal/echocardiogram/plax-ao-root-and-stj-p1a)

 Parasternal short axis RVOT and aortic valve (/course/normal/echocardiogram/psax-rvot-pv-pas-p2a)

 Parasternal short axis pulmonary valve branch Pas (/course/normal/echocardiogram/psax-focused-branch-pas-p2a)

 High parasternal short axis focused on branch pulmonary arteries (/course/normal/echocardiogram/ssn-branch-pas-p5c)

 Parasternal short axis Ao valve zoom (/course/normal/echocardiogram/psax-av-zoom-p2a)

 Parasternal short axis Vent Pap muscle (/course/normal/echocardiogram/psax-vent-pap-muscle-p2b)

 Parasternal short axis Mitral valve (/course/normal/echocardiogram/psax-mitral-valve-p2c)

 Parasternal short axis apex (/course/normal/echocardiogram/psax-apex-p2d)

 Parasternal short axis RCA (/course/normal/echocardiogram/psax-rca-p2a)

 Parasternal short axis LCA (/course/normal/echocardiogram/psax-lca-p2a)

 Apical 4 chamber (/course/normal/echocardiogram/a4c-p3a)

 Apical 4 chamber coronary sinus (/course/normal/echocardiogram/a4c-post-tilt-cs-p3b)

 Apical 4 chamber ejection fraction (/course/normal/echocardiogram/a4c-ejection-fraction)

 Apical 4 chamber tissue Doppler (/course/normal/echocardiogram/tissue-doppler-a4c)

 Apical 5 chamber (/course/normal/echocardiogram/a5c-p3c)

 Apical 2 chamber (/course/normal/echocardiogram/a2c-p3d)

 Apical 4 chamber pulmonary valve (/course/normal/echocardiogram/ata-pv-p3e)

 Subcostal: liver/spine (/course/normal/echocardiogram/subcostal-liver-spine-p4a)

 Subcostal Abd Ao (/course/normal/echocardiogram/subcostal-abd-ao-p4b)

 Subcostal IVC (/course/normal/echocardiogram/subcostal-ivc-p4b)

 Subcostal long axis atrial septum (/course/normal/echocardiogram/sub-long-atrial-septum-p4c)

 Subcostal long axis LVOT (/course/normal/echocardiogram/sub-long-lvot-p4c)

 Subcostal short axis SVC and IVC (/course/normal/echocardiogram/sub-short-svc-and-ivc-p4d)

 Subcostal short axis ventricles (/course/normal/echocardiogram/sub-short-ventricles-p4d)

 Subcostal short axis RVOT (/course/normal/echocardiogram/sub-short-rvot-p4d)

 SSN aortic arch sidedness and branching (/course/normal/echocardiogram/ssn-ao-sidedness-sweep-p5a)

 SSN aortic arch (/course/normal/echocardiogram/ssn-ao-p5b)

 SSN pulmonary veins (/course/normal/echocardiogram/ssn-pulm-vein-p5c)

 SSN svc and innominate vein (/course/normal/echocardiogram/ssn-svc-innominate-p5c)

 High right parasternal svc and atrial septum (/course/normal/echocardiogram/hrp-svc-septum-p6)

First Lesion  (/course/normal/echocardiogram)

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