Echocardiography (eBook)

Dr Petros Nihoyannopoulos is Reader in Cardiology, at the National Heart and Lung Institute, Imperial College School of Medicine and Technology (University of London) and Honorary Consultant Cardiologist Hammersmith Hospital, UK. He is a fully trained clinical cardiologist having completed medical studies in Strasbourg-France in 1979. He is now Head of Echocardiography laboratories at Hammersmith Hospital. Dr Nihoyannopoulos has developed the Hammersmith Echocardiology laboratory to the highest international standards to accommodate the ever increasing clinical demand but also to the highest national teaching center for echocardiology. He organizes both a clinical echocardiography service department with comprehensive technical support and a research unit which annually trains 5-6 post-graduate students from all over the world. At present, he has trained over 50 doctors and technicians from all over Europe in the art of echocardiology. His main research interest is in the use of echocardiography and Doppler techniques in clinical practice. To this end he leads the echocardiography laboratory at the Hammersmith Hospital in the following specific areas: stress echocardiography to assess wall motion in patients with syndrome X; the development of a three-dimensional ultrasound model of the thoracic aorta in health and disease; the use of contrast echocardiography for enhanced doppler signal and improved endocardial border detection and myocardial perfusion at rest and during stress; intravascular ultrasound system to compare imaging with histological plaque appearances. Dr Joseph Kisslo is Professor of Medicine at Duke University, Durham, NC USA. Dr. Kisslo's research has centered around the development and initial application of new ultrasound imaging devices. Focussed principally on morphologic diagnosis in the early years, the work has become progressively more physiologic in its orientation. After more than two decades there are now 300 original research papers, several textbooks and other materials. Dr. Kisslo has distinguished himself as the first to use phased array ultrasound imaging in the human body and, accordingly, was the first to describe most of the disease for which the technique is now commonplace. He was very early into the applications of Doppler color flow imaging and transesophageal imaging with ultrasound. He has served as an officer or on the Board of a variety of national and international bodies. He was one of the first Presidents of the American Society of Echocardiography. He reviews in all aspects of cardiac imaging, but principally echocardiography.Over the past 15 years he has also had a keen interest in medical economics and has served on various professional and governmental boards in describing medical costs and dealing with medical economics. More recently, he has taken interest in adult re-education through remote learning means (telemedicine) and has become the Clinical Director of Telemedicine at Duke. He is Executive Producer of the world's largest telemedicine program (Echo in Context) which has run for the past 14 years. This was the first educational event to circumnavigate the globe live.He is a frequent scientific and motivational lecturer to scientific organizations and industry. He serves as advisor to several governmental and industrial organizations.

Nihoyannopoulos_FM.pdf 1
Nihoyannopoulos_Ch01_O.pdf 12
Chapter 1 13
Physical Principles and the Basic Exam 13
Introduction 13
Basic Concepts 13
Imaging of Cardiac Structures 14
The Ultrasound Beam 14
The 2-D Sector Image 15
M-Mode 16
Attenuation, Reflection and Depth Compensation 18
Reverberation and Multiple Reflection Artifacts 18
Gray Scale 21
Resolution of Ultrasound Images 21
Parallel Processing 23
Harmonic Imaging 25
Transesophageal Imaging 26
Real-Time 3-D Imaging 27
Doppler Echocardiography 28
Doppler Principles 28
Continuous-Wave Spectral Doppler 29
Volumetric Flow 30
The Continuity Equation and Flow Through a Restricting Orifice 30
Pulsed Wave Doppler 32
High PRF PW Doppler 34
Color Flow Imaging 35
Advantages of Color Flow Imaging 36
Limitations of Color Flow Imaging 36
Tissue Doppler Imaging 37
Strain Rate Imaging 37
Second Harmonic Mode Doppler and Contrast Imaging 39
Power Mode (Amplitude) Imaging 39
Is Ultrasound Safe? 40
Conclusions 40
Nihoyannopoulos_Ch02_O.pdf 41
Chapter 2 41
Conducting a Cardiac Ultrasound Examination 41
2D Normal Views 41
Historical Perspective 41
Normal Cardiac Anatomy 42
Transthoracic Standard Imaging Planes 42
Left Parasternal Window 42
Long Axis 42
Short Axis 42
Apical Window 44
Subcostal window 45
Suprasternal Window 46
Transesophageal Standard Imaging Planes 46
Controls Settings 48
Introduction 48
Preparing the Machine 48
Two-Dimensional Imaging and Basic Image Manipulation 49
Measurements 52
Harmonics 52
Annotation 52
Color Doppler 53
Pulsed-Wave and Continuous-Wave Doppler 54
Conclusions 56
Nihoyannopoulos_Ch03_O.pdf 57
Chapter 3 57
Principles of Flow Assessment 57
Introduction 57
The Doppler Principle 57
Principle of Flow Assessment 59
Stroke Volume and Cardiac Output 60
Continuity Equation 61
Clinical Applications of Continuity Equation 62
Mitral Regurgitation 62
Aortic Regurgitation 62
Mitral Stenosis 63
Aortic Stenosis 63
Proximal Isovelocity Surface Area method 66
Clinical Applications of PISA Method 66
Mitral Regurgitation 66
Tricuspid Regurgitation 67
Aortic Regurgitation 68
Mitral Stenosis 70
References 70
Nihoyannopoulos_Ch04_O.pdf 73
Chapter 4 73
Principles of Hemodynamic Assessment 73
Transvalvular Pressure Gradient 73
Aortic Stenosis 73
Pulmonary Stenosis 75
Mitral Stenosis 76
Tricuspid Stenosis 78
Special Considerations with the Use of Simplified Bernoulli Equation 78
Increased Flow Acceleration 78
Increased Viscous Friction 78
Effect of the Angle 78
Increased Proximal Velocity 79
Alteration of the Blood Viscosity 79
Assessment of Intracardiac Pressures 79
Left Atrial Pressure 79
Left Ventricular End-Diastolic Pressures 79
Right Ventricular Pressure 84
Pulmonary Artery Pressures 85
References 86
Nihoyannopoulos_Ch05_O.pdf 89
Chapter 5 89
Tissue Doppler, Doppler Strain, and Non-Doppler Strain: Tips, Limitations, and Applications 89
Doppler Tissue Imaging 89
Principles and Modalities Have Been Published Previously1 89
Requirements for Image Acquisition when Acquiring Color Tissue Doppler Images 89
Postprocessing Analysis 90
Advantages of Tissue Doppler Echocardiography Over Conventional Echocardiography 91
Applications 91
Limitations of Tissue Doppler Echocardiography 95
Doppler Strain and Strain Rate 97
Principle and Modalities 97
Requirements for Image Acquisition 97
Postprocessing Analysis 97
Advantages of Doppler Strain and Strain Rate Over Doppler Tissue Velocity 97
Applications 99
Limitations of Doppler Strain and Strain Rate 101
Non-Doppler Tissue Velocity and Non-Doppler Strain 101
Principle 101
Validation 102
Requirements for Image Acquisition 102
Postprocessing Analysis 102
Normal Values 103
Advantages of STE Over Doppler-Derived Deformation Imaging 105
Applications 106
Limitations 106
Conclusion 108
References 110
Nihoyannopoulos_Ch06_O.pdf 111
Chapter 6 111
Transesophageal Echocardiography: Principles and Application 111
Patient Preparation and Instrumentation 111
Left Ventricle 112
Mitral Valve 114
Aortic Valve 115
Left Atrium 115
Right Ventricle 115
Tricuspid Valve 116
Right Atrium 116
Pulmonary Artery 116
Thoracic Aorta 117
Clinical Applications 117
Infective Endocarditis 117
Evaluation of Prosthetic Valves 117
Cardioembolic Strokes 117
Atrial Fibrillation 118
Aortic Diseases 118
Cardiac Masses 119
Congenital Heart Diseases and Intracardiac Shunts 119
Critically Ill Patients 119
Perioperative and TEE During Procedures 120
Pitfalls 120
Complications 122
Conclusions 123
References 123
Nihoyannopoulos_Ch07_O.pdf 125
Chapter 7 126
Aortic Valve Disease 126
Introduction 126
Etiology 126
Valvular 126
Calcific Degenerative Aortic Stenosis 126
Bicuspid Aortic Valve 126
Rheumatic 128
Vegetations 128
Subvalvular Aortic Stenosis 129
Discrete Subaortic Membrane 129
Hypertrophic Cardiomyopathy 129
Supravalvular Aortic Stenosis 130
Familial Hypercholesterolemia 130
William’s Syndrome 130
The Role of Echocardiography 131
Evaluate the Level of Stenosis and Describe the Anatomy 131
Evaluate Severity of Stenosis 131
Pressure Gradients 131
Aortic Valve Area 132
Advantages of Continuity Equation 133
Problems Using the Continuity Equation 133
Outflow-to-Aortic Velocity Index 134
Valve Resistance 134
Potential Advantages 134
Summary 134
Aortic Stenosis and Left Ventricular Dysfunction 135
Clinical Decision Making 135
Conclusions 135
B. Aortic Regurgitation 136
Introduction 136
Etiology of Aortic Regurgitation (Table 7.2) 136
Degenerative Disease 136
Rheumatic 136
Congenital 137
Endocarditis 137
Connective Tissue Disease 138
Inflammatory Aortitis 139
Aortic Dissection 139
Others 139
Methods of Assessing Aortic Regurgitation 139
Doppler Methods 139
Color-Flow Doppler 139
Regurgitant Jet Size 139
Flow Convergence or PISA 140
Vena Contracta 140
Pulsed and Continuous-Wave Doppler 140
Quantitative Flow Methods (See Also Chap. 3) 140
Aortic Diastolic Flow Reversal 141
Signal Density 141
Diastolic Jet Deceleration 141
Assessment of Ventricular Function 141
Acute vs. Chronic Aortic Regurgitation 142
Conclusion 143
References 143
Nihoyannopoulos_Ch08_O.pdf 144
Chapter 8 144
Mitral Valve Disease 144
Cardiac Anatomic Relationships 144
Parasternal Long Axis 144
Parasternal Short Axis 149
Apical views 151
The Surgical View 154
Functional Mitral Valve Anatomy 157
Functional Anatomic Segments 157
Functional Nomenclature in Other Views 157
Mitral Valve Spatial Movement and Flow Profiles 161
Cyclical Mitral Valve Movement 161
Normal Doppler Mitral Profiles 163
Comprehensive Evaluation of Mitral Regurgitation 165
Calculations of Jet Severity 167
Mitral Timing Relationships 167
Relationships of Spectral Doppler 168
Use of Color-Flow Doppler Controls 169
Use of Color Gain 170
Altered Nyquist (or Scale Factor) 174
Effect of Frame Rate and Persistence 174
Excess Image Gain 174
System Setting Variability in Jet Size 176
Jet Duration 176
Hints from Spectral Doppler 179
Mitral Stenosis 181
Planimetry of the Mitral Orifice 185
Mean Mitral Gradient by Doppler 187
Pressure Half-Time Mitral Valve Area 187
Mitral Prolapse 191
Functional Classification of Mitral Regurgitation 192
Typical Type II, P2 Leaflet Prolapse 193
Typical Type II, A2 Leaflet Prolapse 196
Visualization of Other Mitral Procedures 198
Mitral Regurgitation and Congestive Heart Failure 202
Mitral Annular Calcification 204
Infective Vegetative Endocarditis 207
Left Atrial Myxoma 210
Congenital Anomalies of the Mitral Valve 216
References 222
Nihoyannopoulos_Ch09_O.pdf 223
Chapter 9 223
Tricuspid and Pulmonic Valve Disease 223
Tricuspid Valve 223
Tricuspid Regurgitation 223
Etiology 223
Functional 223
Infective Endocarditis 224
Ebstein’s Anomaly 225
Rheumatic Heart Disease and Carcinoid 225
Miscellaneous Etiologies 226
Assessment of TR Severity 226
Two-Dimensional Criteria 226
Color Doppler 226
Continuous-Wave Doppler 228
Pulsed Doppler 228
Tricuspid Stenosis 229
Etiology 229
Rheumatic 229
Carcinoid 229
Eosinophilic 229
Metabolic and Others 229
Assessment of Severity 229
Pulmonic Valve 231
Pulmonic Stenosis 231
Assessment of Severity 231
Pulmonic Regurgitation 232
Assessment of Severity 233
Color Doppler 233
Continuous-Wave Doppler 233
Pulsed Doppler 234
Conclusion 235
Bibliography 235
Nihoyannopoulos_Ch10_O.pdf 236
Chapter 10 236
Pulmonary Hypertension Clinical Echocardiography 236
Clinical Background 236
Pathophysiology 236
Clinical Classification 237
Prognosis 238
Role of Echocardiography in Pulmonary Hypertension 238
Screening for Pulmonary Hypertension 238
Definition of Pulmonary Hypertension 238
Other Signs to Look for 240
Estimation of Pulmonary Vascular Resistance 240
Management of Mild Pulmonary Hypertension Detected by Echocardiography 242
Etiology of Pulmonary Hypertension 242
Congenital Heart Disease 242
Left Heart Disease 242
Other Causes 243
Estimation of Severity of Pulmonary Hypertension 244
Two-Dimensional and M-Mode Echocardiography 244
Pericardial Effusion 244
Right Atrial Enlargement and Pressure 244
Right Ventricular Size and Function 245
Interventricular Septal Shift 245
Left Ventricular Size and Function 247
Patent Foramen Ovale 247
Doppler Assessment 247
Tricuspid Regurgitation Velocity and Calculated Systolic Pulmonary Arterial Pressure 247
Pulmonary Arterial Mean and Diastolic Pressure 248
Assessment of Right Ventricular Function 250
Right Ventricular Doppler Index 250
Tricuspid Regurgitation Severity 250
Tissue Doppler Imaging of Right Ventricle 251
Assessment of Left Ventricular Function 251
Left Ventricular Filling 251
Cardiac Index 251
Serial Echocardiographic Monitoring 251
Detecting Complications 252
Role of Other Imaging Modalities 254
Conclusions 256
Bibliography 256
Nihoyannopoulos_Ch11_O.pdf 257
Chapter 11 257
Criteria for Operative Intervention in Valvular Heart Disease Based on Echocardiography 257
Aortic Stenosis 257
Gradients in Aortic Stenosis 258
Valve Area in Aortic Stenosis 258
Criteria for Operation for Aortic Stenosis in Asymptomatic Patients 259
Aortic Regurgitation 259
LV Size and Function in Aortic Regurgitation 260
Mitral Stenosis 261
Mitral Regurgitation 266
Summary 269
Bibliography 269
Nihoyannopoulos_Ch12_O.pdf 270
Chapter 12 270
Clinical Echocardiography Prosthetic Valves 270
Introduction 270
Classification of Valves 270
Mechanical Valves 270
Biological Valves 270
Position and Sizing 272
Complications 273
Criteria for Use 274
Echocardiography 274
Appearance 275
Does the Valve Rock? 275
Check the Occluder 276
Forward Flow 276
Regurgitation 276
Detection of Early Failure 278
Detection of Obstruction 279
Mitral Position 279
Aortic Position 280
Tricuspid Position 280
Cause of Obstruction 280
Regurgitation 281
Is It Pathological? 281
Quantification 281
Endocarditis 283
Timing of Echocardiography 284
Preoperative 284
Planning a Ross procedure 284
Planning a Stentless Valve 284
Endocarditis 284
Planning a Homograft 284
Other Valves 284
Right Ventricular Function 285
Perioperative 285
Baseline Study 285
Late After Surgery 285
When Is TOE Necessary? 285
Conclusions 286
Glossary 286
Appendix: Normal Ranges for Replacement Heart Valves: Mean (Standard Deviation) 286
Bibliography 287
Nihoyannopoulos_Ch13_O.pdf 288
Chapter 13 288
The Use of Echocardiography in the Diagnosis and Treatment of Patients with Infective Endocarditis 288
Introduction 288
Diagnosis of Endocarditis: The Duke Criteria and the Importance of Imaging 288
Echocardiographic Evidence of Infective Endocarditis 289
Vegetation 290
Periannular Extension of Infection (Myocardial Abscess Formation) 292
Fistula Formation 293
Perforation 294
New Valvular Regurgitation 294
Dehiscence of Prosthetic Valve 295
The Use and OverUse of Echocardiography to Make the Diagnosis of IE 295
Use of Echocardiography in Patients Suspected of IE 295
Overuse of Echocardiography 295
TTE vs. TEE 296
Cost Effectiveness of Diagnostic Imaging Strategies 296
Echocardiography to Predict Complications and Guide Therapeutic Decision Making 296
Special Considerations in Patients with IE 297
Prosthetic Valve IE 297
Right-Sided IE 297
Intracardiac-Device-Related Infections 298
Consideration for Multiple Echocardiographic Evaluations 298
Other Imaging Modalities in IE 298
Conclusions 299
References 299
Nihoyannopoulos_Ch14_O.pdf 300
Chapter 14 301
Pericardial Effusion, Tamponade, and Constriction 301
Anatomy, Function, and Physiology of the Pericardium 301
Diseases of the Pericardium 301
Congenital Absence of the Pericardium 301
Pericardial Cyst 301
Pericardial Tumors 301
Pericardial Effusion and Tamponade 302
Etiologies 302
Clinical Features 302
Echocardiographic Features 303
Echo-Guided Pericardiocentesis 305
Differentiating Pericardial Effusion from Pleural Effusion 307
Pericardial Constriction 307
Pathophysiology and Etiologies 307
Clinical Features 308
Echocardiographic Findings 308
Differentiating Constriction from Restriction 311
Differentiating Constriction from Chronic Obstructive Lung Disease 311
Diagnosing Constriction in Atrial Fibrillation 312
Effusive-Constrictive Disease 312
Role of CT and MR Imaging in Pericardial Disease 312
Conclusion and Practical Tips 313
Bibliography 314
Nihoyannopoulos_Ch15_O.pdf 315
Chapter 15 316
Clinical Echocardiography 316
Introduction 316
Regional Wall Motion Abnormality: How Does It Occur? The Mechanism for RWMA 316
Wall Motion vs. Systolic Wall Thickening for the Assessment of CAD 317
Basic Anatomy and Echocardiographic Findings 317
Assessment of Regional Wall Motion 320
Acute Myocardial Infarction 321
Echocardiographic Assessment in AMI 322
Acute Coronary Syndromes 324
Echocardiography in Acute Coronary Syndromes 324
Improving Endocardial Definition 324
Harmonic Imaging 324
Left Ventricular Opacification Using Contrast Agents 325
Automated Endocardial Border Tracking 325
References 327
Nihoyannopoulos_Ch16_O.pdf 328
Chapter 16 328
Stress Echocardiography 328
Pathophysiology 328
Stress Testing 328
Selection of Stress Method 328
Which Stressor? 329
Acquisition 331
Equipment 331
Harmonic Imaging 331
Contrast Imaging 331
Image Acquisition 331
Digital Image Acquisition 331
The “Roadmap” for Good Acquisition 332
Interpretation 333
Semiquantitative Interpretation 333
Structured Review 334
Resting Function 334
Defining an Ischemic Response 335
The Magnitude of Ischemia 337
Rules for Qualitative Interpretation 337
Pitfalls in the Standard Performance of Stress Echocardiography 337
Quantitative Interpretation 339
Accuracy 344
Clinical Factors Influencing Accuracy 344
Accuracy of Stress Echocardiography 344
Exercise Versus Pharmacologic Stress 345
Selection of the Optimal Pharmacologic Stress 345
Comparison with Other Approaches 345
Comparison with the Exercise ECG 345
Difficult Subgroups for Standard Exercise Testing (LBBB, LVH, Women) 346
Clinical Implications of Superiority of Exercise Echo Versus Exercise ECG 346
Comparison with Other Stress-Imaging Approaches 346
Accuracy of Stress Echocardiography Versus Perfusion Scintigraphy 347
When to Choose Stress Echocardiography Versus Scintigraphy (and Vice Versa) 347
Stress Echocardiography Versus Magnetic Resonance Imaging 348
Echocardiographic Determination of Myocardial Viability 348
Use of Echocardiographic Techniques to Predict Functional Recovery 348
Comparison with Other Approaches for the Detection of Myocardial Viability 348
Prognostic Value of Stress Echocardiography 349
Significance of a Negative Stress Echocardiogram 350
Significance of a Positive Stress Echocardiogram 350
Prognostic Assessment After Myocardial Infarction 350
Prediction of Perioperative Cardiac Risk in Patients Undergoing Major Noncardiac Surgery 351
Use of Stress Echocardiography in Noncoronary Heart Disease 352
Stress Echo in Valvular Heart Disease 352
Conclusions 352
References 352
Nihoyannopoulos_Ch17_O.pdf 354
Chapter 17 354
Principles of Myocardial Viability Implications for Echocardiography 354
Introduction 354
Historical Perspective 354
Pathophysiology 355
Observations in Humans with Chronic Reversible Ischemic Dysfunction 355
Insights Gained from Animal Models of Chronic Reversible Ischemic Dysfunction 359
The Physiological Spectrum of Myocardial Viability 359
Implications for the Clinical Identification of Viable Myocardium 361
Basic Principles for the Identification of Viable Myocardium (Table 17.2) 361
The Working Hypothesis 362
Role of Echocardiography 363
How Echo Is Useful 363
Echocardiography at Rest 364
Myocardial Contrast Echocardiography 365
Stress Echocardiography 366
Conclusions 367
Bibliography 368
Nihoyannopoulos_Ch18_O.pdf 369
Chapter 18 369
Echocardiography for Assessing Acute Myocardial Infarction 369
Introduction 369
Acute Chest Pain 369
Workup in Acute Chest Pain Syndromes 370
Diagnosis of MI 371
Extent of MI 371
Stress Echocardiography in the Emergency Room 373
Prognosis After MI 374
Regional Left Ventricular Function 374
Compensatory Hyperkinesia and Remote Asynergy (Remodeling) 376
Quantitating Left Ventricular Function 377
Ischemic Mitral Regurgitation 379
Mechanisms 379
Left Ventricular Diastolic Function 380
Left Ventricular Spatial Flow Pattern 381
Left Ventricular Thrombi 382
Myocardial Viability 382
Residual Myocardial Ischemia 382
Future Developments 384
Clinical Recommendations and Implications 384
Bibliography 385
Nihoyannopoulos_Ch19_O.pdf 386
Chapter 19 386
Mechanical Complications of Myocardial Infarction 386
Rupture of LV Free Wall 386
Echocardiographic Findings 387
Transesophageal Echocardiography and AMI Complications 388
LV Pseudoaneurysm 389
Echocardiographic Findings 389
Ventricular Septal Rupture 390
Echocardiographic Findings 391
Papillary Muscle Rupture 394
Echocardiographic Findings 394
Left Ventricular Aneurysm and Thrombus Formation 395
Summary 397
Bibliography 397
Nihoyannopoulos_Ch20_O.pdf 399
Chapter 20 399
Cardiomyopathies 399
Introduction 399
Hypertrophic Cardiomyopathy 399
Definitions 399
Pathology 399
Pathophysiology 399
Diagnosis 401
The Role of Echocardiography 401
Patterns of LV Hypertrophy 404
Diagnostic Difficulties 406
The Mitral Apparatus 410
The Aortic Valve 410
Doppler Echocardiography 410
Diastolic Events 411
Systolic Events 412
The Role of Tissue Doppler Imaging 415
Predictors of Prognosis 418
Dilated Cardiomyopathy 419
Idiopathic (Primary) Dilated Cardiomyopathy 419
The Role of Echocardiography 420
Doppler Echocardiography 421
Mitral Regurgitation 421
Estimate of LV Pressures 421
Intracardiac Flow and Risk o.f Embolization 422
Tissue Doppler Imaging 422
Family Screening 423
Myocarditis 423
Cardiac Toxins 423
Cardiomyopathy Associated with Pregnancy and Parturition 424
Isolated Left Ventricular Noncompaction 425
Restrictive Cardiomyopathy 426
Types of Restrictive Cardiomyopathies 426
Cardiac Amyloidosis 426
Eosinophilic Endomyocardial Disease 427
Idiopathic (Primary) Restrictive Cardiomyopathy 430
Restrictive Physiology 430
Distinction Between Restrictive Cardiomyopathy and Constrictive Pericarditis 430
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy 431
Definitions and Pathophysiology 431
Criteria for Diagnosis of ARVD/C 432
Echocardiographic Characteristics 432
Conclusions 434
References 434
Nihoyannopoulos_Ch21_O.pdf 435
Chapter 21 435
Echocardiography in Heart Failure 435
Clinical Staging and Etiology of Heart Failure: Role of Echocardiography 435
Quantification of Systolic Dysfunction 438
Quantification of Diastolic Dysfunction 439
Indices for Assessing Diastolic Dysfunction 439
Mitral Inflow Velocities 439
Pulmonary Venous Doppler Velocities 440
Mitral Annular Velocities 441
Flow Propagation 441
Other Doppler Variables in Hemodynamic Assessment 441
Diastolic Function Assessment and Risk Stratification 441
Echocardiography for Guiding Management Strategies in Heart Failure 442
Therapeutic and Surgical Interventions 442
Echocardiography in Critical Care Units 442
Role of Echocardiography in Cardiac Resynchronization 442
Echocardiography and Heart Failure Screening 443
Summary and Future Directions 444
References 445
Nihoyannopoulos_Ch22_O.pdf 446
Chapter 22 446
Cardiac Resynchronization Therapy 446
Introduction 446
What Is Cardiac Dyssynchrony? 446
Types of Mechanical Dyssynchrony 447
AtrioVentricular Dyssynchrony 447
Interventricular Dyssynchrony 448
Intraventricular Dyssynchrony 449
How to Assess Intraventricular Dyssynchrony: Prediction of Responders 449
Echocardiographic Assessment and Quantification of Dyssynchrony 449
M-Mode Echocardiography 449
Summary 449
Two-Dimensional Echocardiography 449
Real-Time 3D Echocardiography in the Assessment of Mechanical Dyssynchrony 450
Evaluation of Global and Regional Volumes and Function 451
RT3DE and Intraventricular Dyssynchrony Assessment 451
Dyssynchrony Index 452
Summary 453
Tissue Velocity Imaging and Deformation Parameters 453
Summary 453
Summary 455
Summary 457
Summary 458
Determining Optimal Lead Placement During Implantation 458
AtrioVentricular (AV) Optimization 458
Evaluating the Reverse Remodeling of the Heart During Follow-Up 458
Reversal of LV Dilatation (Reversed Remodeling) 459
Improved Diastolic Function 459
Effect of CRT on Mitral Regurgitation 459
Conclusions 459
References 459
Nihoyannopoulos_Ch23_O.pdf 461
Chapter 23 462
Intracardiac Masses 462
Left Ventricular Thrombi 462
Myxomas 465
Other Benign Tumors 466
Malignant Tumors 467
Scanning Techniques 467
Limitations 467
References 467
Nihoyannopoulos_Ch24_O.pdf 469
Chapter 24 469
Aortic Disorders 469
Aortic Imaging 469
Introduction 469
Transthoracic Imaging 469
Transesophageal Imaging 469
Aortic Aneurysm 471
Definition 471
Etiologies 471
Pseudoaneurysms 471
Aortic Rupture 471
Imaging 472
Aortic Dissection 472
Imaging 472
Pathophysiology 472
Etiologies 473
Classification 473
Clinical Presentation 474
Echocardiographic Findings 474
The Intimal Flap 474
False Lumen 474
Coronary Arteries 474
Aortic Regurgitation 475
Pericardial Effusion 475
Surgery 475
Intramural Hematoma 475
Imaging 476
Clinical Significance 478
Penetrating Aortic Ulcers 478
Pathophysiology 478
Clinical Significance 479
Imaging 479
Aortic Trauma 479
Pathophysiology 479
Imaging 480
Aortic Atheromatous Disease 480
Pathophysiology 480
Classification 481
Clinical Significance 481
Imaging 482
References 482
Nihoyannopoulos_Ch25_O.pdf 484
Chapter 25 484
Source of Embolus 484
Introduction 484
Epidemiology 484
Potential Cardiovascular Sources of Embolus 484
When to Use Echocardiography to Investigate for a Potential Cardiac Source of Embolus 485
Transthoracic vs. Transesophageal Echocardiography 486
Left Atrium 487
Anatomy 487
Left Atrial Appendage Doppler 490
Echocardiographic Assessment of the Left Atrium (Figs. 25.2–25.8) 490
Left Atrial Thrombus (Figs. 25.4, 25.5, 25.8) 492
Factors Associated with Left Atrial Thromboembolism in Atrial Fibrillation 492
Left Atrial Spontaneous Echo Contrast 493
Spontaneous Echo Contrast and Thromboembolism 494
Left Atrial Tumors 494
Left Atrial Myxoma 494
Left Ventricular Thrombus 495
Echocardiographic Identification 495
Risk of Embolization 495
Valvular Vegetations 496
Echocardiographic Features 496
Factors Associated with Vegetation Embolism 497
Prosthetic Valves 497
Fibrinous Strands/Lambl’s Excrescences 497
Papillary Fibroelastoma 498
Mitral Stenosis 498
Mitral Annular Calcification 499
Mitral Valve Prolapse 499
Patent Foramen Ovale and Atrial Septal Aneurysm 499
Anatomy 499
Echocardiography 500
Potential Mechanisms of Stroke 501
Association of PFO with Embolic Events 501
Factors Associated with Increased Risk 502
Treatment 502
Thoracic Aortic Atheroma 503
Echocardiographic Assessment 503
Association of Thoracic Aortic Atheroma and Stroke 504
Emboli During Aortic Manipulation 504
Management of Patients with Aortic Atheroma 505
Overall Approach to Evaluation 505
Impact of Echocardiography on Patient Management 505
Bibliography 505
Nihoyannopoulos_Ch26_O.pdf 506
Chapter 26 507
Simple Congenital Heart Defects 507
Introduction 507
Segmental Approach to Cardiac Anatomy 507
Shunts and Septal Defects 507
Atrial Septal Defect 507
Anatomy and Physiology 507
Echocardiographic Evaluation 508
Cautions 509
Atrioventricular Septal Defect 509
Anatomy and Physiology 509
Echocardiographic Evaluation 511
Cautions 511
Ventricular Septal Defect 511
Anatomy and Physiology 511
Echocardiographic Evaluation 512
Cautions 512
Patent Ductus Arteriosus 513
Anatomy and Physiology 513
Echocardiographic Examination 513
Cautions 514
Valvular Abnormalities 514
Pulmonary Stenosis 514
Anatomy and Physiology 514
Echocardiographic Evaluation 514
Cautions 514
Aortic Stenosis 515
Anatomy and Physiology 515
Echocardiographic Evaluation 515
Cautions 516
Coarctation of the Aorta 516
Anatomy and Physiology 516
Echocardiographic Evaluation 516
Cautions 517
Ebstein Anomaly of the Tricuspid Valve 517
Anatomy and Physiology 517
Echocardiographic Evaluation 517
Cautions 518
References 518
Nihoyannopoulos_Ch27_O.pdf 519
Chapter 27 519
Echocardiographic Evaluation of Complex Congenital Heart Disease 519
Introduction 519
Tetralogy of Fallot 519
Pathology 519
Preoperative Evaluation 519
Surgical Repair 520
Postoperative Evaluation 520
Tetralogy of Fallot with Pulmonary Atresia 521
Pathology 521
Preoperative Evaluation 521
Surgical Repair 521
Postoperative Evaluation 521
Truncus Arteriosus 521
Pathology 521
Preoperative Evaluation 521
Surgical Repair 522
Postoperative Evaluation 522
Common Atrioventricular Canal Defect 522
Pathology 522
Preoperative Evaluation 522
Surgical Repair 523
Postoperative Evaluation 523
d-Loop Transposition of the Great Arteries 523
Pathology 523
Preoperative Evaluation 524
Surgical Repair 525
Postoperative Evaluation 525
Hypoplastic Left Heart Syndrome 526
Pathology 526
Preoperative Evaluation 526
Surgical Repair 526
Postoperative Evaluation 527
Shone Syndrome 527
Pulmonary Atresia with Intact Ventricular Septum 529
Pathology 529
Preoperative Evaluation 529
Surgical Repair 529
Postoperative Evaluation 530
Tricuspid Atresia 530
Pathology 530
Preoperative Evaluation 530
Surgical Repair 530
Postoperative Evaluation 531
Double Outlet Right Ventricle 531
Pathology 531
Surgical Repair 531
Preoperative Evaluation 532
Postoperative Evaluation 533
Summary 533
References 533
Nihoyannopoulos_Ch28_O.pdf 534
Chapter 28 534
Adult Congenital Heart Disease 534
General Principles 534
Sequential Segmental Analysis and Normal Anatomy 534
Transesophageal Echocardiography 535
Contrast Echocardiography 535
Atriums and Great Veins 536
Anomalous Venous Drainage 536
Cor Triatriatum 536
Atrial Septal Defects 537
Patent Foramen Ovale 541
Partial Atrioventricular Septal Defect (Ostium Primum ASD) 541
Complete Atrioventricular Septal Defect 542
Atrioventricular Valves 543
Mitral Valve 543
Tricuspid Valve 543
Tricuspid Regurgitation 543
Atrioventricular Connections 544
Discordant Atrioventricular Connections 544
Tricuspid Atresia, Mitral Atresia, Double Inlet Left Ventricle 544
Palliated “Single-Pump” Disease 545
Pulmonary Artery Banding 545
Shunts and the Fontan Circulation 545
Ventricles 546
Ventricular Septal Defect 546
Left ventricular Outflow Obstruction 547
Right Ventricular Outflow Obstruction 548
Tetralogy of Fallot and Pulmonary Atresia with Ventricular Septal Defect 549
Aortic Root Enlargement and Aortic Regurgitation 551
Pulmonary Atresia with Multifocal Aortopulmonary Collaterals 551
Ventriculoarterial Connections 551
Transposition of the Great Arteries 551
Congenitally Corrected Transposition of the Great Arteries 553
The Great Arteries 553
Patent Ductus Arteriosus 553
Coronary Arteries 555
Coarctation of the Aorta 556
Common Arterial Trunk 557
Double Outlet Right Ventricle 557
Endocarditis 557
Pregnancy 558
Bibliography 558
Nihoyannopoulos_Ch29_O.pdf 559
Chapter 29 560
Intraoperative Echocardiography 560
Epicardial vs. Transesophageal Echocardiography 560
Essentials of the IOE Exam 560
Prepump IOE 560
Postpump IOE 561
Process and Completeness of the IOE Study 562
Indications for Intraoperative Echo 562
IOE in Mitral Valve Repair 562
IOE in Left Ventricular Outflow Tract Surgery 564
IOE in Coronary Atherosclerosis 566
IOE in Other Cardiac Conditions 567
Complications of Heart Surgery Definable by IOE 567
Pitfalls of IOE 568
Summary 568
Bibliography 569
Nihoyannopoulos_Ch30_O.pdf 571
Chapter 30 571
Contrast Echocardiography 571
Introduction 571
Basic Principles 571
Types of Contrast Agent 571
Contrast Microbubble Response to Ultrasound 571
Destructive Imaging Techniques 573
Nondestructive Imaging Techniques 574
Enhancement of Doppler Signals 576
Contrast Administration: Bolus or Infusion? 577
Left Ventricular Opacification 577
LV Thrombus and Masses 578
Global and Regional LV Function 579
Stress Echocardiography 581
Myocardial Perfusion 583
Stress Myocardial Perfusion 583
Acute Coronary Syndromes 588
Myocardial Viability Studies 589
Future of Contrast Echo 590
Drug Delivery 590
3D Contrast Studies 590
Conclusion 591
Nihoyannopoulos_Ch31_O.pdf 592
Chapter 31 592
Three-Dimensional Echocardiography 592
Three-Dimensional Imaging Techniques (Table 31.1) 592
Clinical Uses (Table 31.3) 595
Conclusion 604
Keypoints 605
References 605
Nihoyannopoulos_Ch32_O.pdf 608
Chapter 32 608
Ultrasound Stethoscopy 608
Introduction 608
A Historical Perspective 608
The Equipment 608
Clinical Uses 611
More Reliable Examination 611
Point of Care for Faster Decisions 612
Critical Care Environment 614
Screening 618
Abdominal Aortic Aneurysm Screening 618
LV Dysfunction Screening 618
Mitral Valve Prolapse Screening 618
Screening of Athletes 619
Screening for LV Hypertrophy 620
Cost Effectiveness 621
Training Requirements Using Ultrasound Stethoscopy 622
Future Directions 622
Conclusion 622
References 624
Nihoyannopoulos_Ch33_O.pdf 626
Chapter 33 626
Echo-Guided Interventions 626
Introduction 626
ACC/AHA/ASE Guidelines for the Clinical Application of Echocardiography 626
Echocardiographic Modalities Used to Guide Interventional Procedures 627
TTE-Guided Pericardiocentesis 627
Transseptal Catheterization 628
Percutaneous Balloon Valvuloplasty 628
Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy 631
Transesophageal Echocardiography in ASD and PFO Closure 633
TEE in Complex MV Procedures 633
Intracardiac Echocardiography 634
Percutaneous Transcatheter Aortic Valve Replacement 639
Real-Time 3D Echocardiography 639
Interventional Echocardiographic Collaboration 639
References 640
Nihoyannopoulos_Index_O.pdf 643