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Feigenbaum Echocardiography History
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Feigenbaum Echocardiography Dvd
Preface
xiv
Acknowledgments
xv
Chapter 1 History of Echocardiography 1
Harvey Feigenbaum, MD
Development of Various Echocardiographic Technologies 2
Recording Echocardiograms 5
Cardiac Sonographers 5
Echocardiographic Education and Organizations 6
References 7
Chapter 2 Physics and Instrumentation 9
Physical Principles 9
Interaction Between Ultrasound and Tissue 10
The Transducer 12
Manipulating the Ultrasound Beam 14
Resolution 16
Creating the Image 17
Transmitting Ultrasound Energy 19
Display Options 20
Tradeoffs in Image Creation 22
Signal Processing 22
Tissue Harmonic Imaging 23
Artifacts 25
Doppler Echocardiography 26
Principles of Doppler Ultrasound 26
Doppler Formats 29
Color Flow Imaging 32
Technical Limitations of Color Doppler Imaging 33
Doppler Artifacts 34
Tissue Doppler Imaging 35
Biologic Effects of Ultrasound 35
Suggested Readings 37
Chapter 3 Specialized Echocardiographic Techniques and Methods 39
Imaging Devices and Methods 39
M-Mode Echocardiography 39
Two-dimensional Echocardiography 40
Color B-Mode Scanning 40
Doppler Interrogation 40
Color Flow Doppler Imaging 43
Color Doppler M-Mode Imaging 43
Doppler Tissue Imaging 45
Speckle Tracking 48
iv
Contents v
Tissue Characterization 50
Acquisition of Cardiac Ultrasound Information 51
Transthoracic Echocardiography 51
Hand-Carried Ultrasound 52
Dedicated Single-Line Interrogation Transducers 52
Transesophageal Echocardiography 53
Three-dimensional Echocardiography 55
Epicardial Imaging 61
Intracardiac Echocardiography 62
Intravascular Ultrasound 63
The Digital Echo Laboratory 63
Suggested Readings 66
Chapter 4 Contrast Echocardiography 67
Source of Ultrasound Contrast 67
Contrast Agents 67
Safety 69
Clinical Use 69
Ultrasound Interaction with Contrast Agents 70
Detection Methods 71
Machine Settings 71
Intermittent Imaging 72
Low Mechanical Index Imaging 72
Other Mechanical Factors Affecting Contrast Detection 72
Doppler Imaging 73
Contrast Artifacts 73
Detection and Utilization of Intracavitary Contrast 76
Intramural Cavity Flow, Trabeculation, Incomplete Filling 77
Enhancement of Doppler Signals 78
Shunt Detection 81
Detection of Miscellaneous Conditions 84
Myocardial Perfusion Contrast Echocardiography 85
Suggested Readings 89
Chapter 5 The Echocardiographic Examination 91
Selecting the Transducers 93
Patient Position 93
Placement of the Transducer 95
An Approach to the Transthoracic Examination 96
Parasternal Long-Axis Views 96
Parasternal Short-Axis Views 97
Apical Views 102
The Subcostal Examination 106
Suprasternal Views 107
Orientation of Two-Dimensional Images 108
Echocardiographic Measurements 111
Left Ventricular Wall Segments 112
M-Mode Examination 113
Transesophageal Echocardiography 114
Transesophageal Echocardiographic Views 115
Echocardiography as a Screening Test 120
Training in Echocardiography 120
Suggested Readings 120
Chapter 6 Evaluation of Systolic Function of the Left Ventricle 123
General Principles 123
Linear Measurements 123
Indirect M-Mode Markers of Left Ventricular Function 125
Two-dimensional Measurements 126
Assessment of Left Ventricular Function with Three-dimensional Echocardiography 128
Determination of Left Ventricular Mass 131
Physiologic Versus Pathologic Hypertrophy 132
vi Contents
Regional Left Ventricular Function 133
Quantitative Techniques 133
Nonischemic Wall Motion Abnormalities 135
Premature Ventricular Contractions 139
Paced Rhythms 139
Ventricular Preexcitation 139
Postoperative Cardiac Motion 140
Posterior Compression 141
Pericardial Constriction 142
Doppler Evaluation of Global Left Ventricular Function 142
Myocardial Performance Index 143
Other Techniques for Determination of Left Ventricular Systolic Function 144
Determination of Left Ventricular dP/dt 145
Newer and Advanced Methods for Evaluating Left Ventricular Function 146
Strain and Strain Rate Imaging 148
Ventricular torsion 155
Conclusion 155
Suggested Readings 156
Chapter 7 Evaluation of Left Ventricular Diastolic Function 159
Normal Diastolic Function 159
Stages of Diastolic Dysfunction 160
Normal Diastolic Function 160
Impaired Relaxation, Grade I 161
Pseudonormalization, Grade II 162
Restrictive Filling (Reversible), Grade III 162
Restrictive Filling (Irreversible), Grade IV 163
Echo-Doppler Parameters of Diastolic Function 163
Isovolumic Relaxation Time 163
Mitral Inflow 164
Color M-mode Flow Propagation Velocity (Vp) 165
Tissue Doppler Mitral Annular Velocity 166
Pulmonary Venous Flow Patterns 167
Left Atrial Volume 169
The Valsalva Maneuver 171
Other Markers of Diastolic Dysfunction 171
A Comprehensive Approach to Diastolic Dysfunction 172
Estimating Left Ventricular Filling Pressures 175
Stress Testing to Assess Diastolic Function 175
The Differential Diagnosis of Heart Failure with Normal Ejection Fraction 180
Evaluation of Diastolic Dysfunction in Specific Patient Groups 180
Sinus Tachycardia 180
Atrial Fibrillation 181
Mitral Valve Disease 181
Hypertrophic Cardiomyopathy 181
Prognosis in Patients with Diastolic Dysfunction 181
Suggested Readings 182
Chapter 8 Left and Right Atrium, and Right Ventricle 185
Left Atrium 185
Left Atrial Dimensions and Volume 185
Left Atrial Function 188
Atrial Septum 190
Pulmonary Veins 193
Right Atrium 196
Right Atrial Thrombi 199
Right Atrial Blood Flow 200
Right Ventricle 203
Right Ventricular Dimensions and Volumes 204
Right Ventricular Overload 209
Right Ventricular Dysplasia 213
Suggested Readings 214
Contents vii
Chapter 9 Hemodynamics 217
Use of M-Mode and Two-Dimensional Echocardiography 217
Quantifying Blood Flow 218
Clinical Application of Blood Flow Measurement 221
Measuring Pressure Gradients 223
Applications of the Bernoulli Equation 228
Determining Pressure Half-Time 233
The Continuity Equation 236
Proximal Isovelocity Surface Area 237
Myocardial Performance Index 239
Suggested Readings 240
Chapter 10 Pericardial Diseases 241
Clinical Overview 241
Echocardiographic Evaluation of the Pericardium 241
Detection and Quantitation of Pericardial Fluid 242
Direct Visualization of the Pericardium 246
Differentiation of Pericardial from Pleural Effusion 248
Cardiac Tamponade 248
Echocardiographic Findings in Cardiac Tamponade 249
Doppler Findings in Tamponade 251
Pericardial Constriction 254
Echocardiographic Diagnosis 254
Doppler Echocardiographic Findings in Constriction 256
Effusive Constrictive Pericarditis 257
Constrictive Pericarditis Versus Restrictive Cardiomyopathy 258
Miscellaneous Pericardial Disorders and Observations 259
Postoperative Effusions 259
Echocardiography-Guided Pericardiocentesis 260
Congenital Absence of the Pericardium 261
Pericardial Cysts 261
Suggested Readings 262
Chapter 11 Aortic Valve Disease 263
Aortic Stenosis 263
Doppler Assessment of Aortic Stenosis 266
Other Approaches to Quantifying Stenosis 275
Defining the Severity of Aortic Stenosis 275
Dobutamine Echocardiography in the Evaluation of Aortic Stenosis 276
Natural History of Aortic Stenosis 276
Clinical Decision Making 278
Aortic Regurgitation 280
Appropriateness Criteria 280
M-Mode and Two-dimensional Imaging 280
Establishing a Diagnosis of Aortic Regurgitation 283
Evaluating the Severity of Aortic Regurgitation 286
Acute versus Chronic Aortic Regurgitation 291
Assessing the Left Ventricle 291
Miscellaneous Abnormalities of the Aortic Valve 293
Suggested Readings 293
Chapter 12 Mitral Valve Disease 295
Anatomy of the Mitral Valve 295
Physiology of Mitral Valve Disease 297
Mitral Stenosis 297
Two-Dimensional Echocardiography in Rheumatic Mitral Stenosis 298
Congenital Mitral Stenosis 301
M-Mode Echocardiography 301
Transesophageal Echocardiography 302
Role of Three-Dimensional Echocardiography 303
Anatomic Determination of Severity 303
Doppler Echocardiographic Determination of Severity 304
viii Contents
Exercise Gradients 307
Secondary Features of Mitral Stenosis 307
Atrial Fibrillation 309
Secondary Pulmonary Hypertension 310
Decision Making Regarding Intervention 310
Mitral Regurgitation 310
Doppler Evaluation of Mitral Regurgitation 311
Flail Leaflets 313
Functional Mitral Regurgitation 318
Determination of Mitral Regurgitation Severity 320
Other Considerations in Assessing Mitral Regurgitation 324
Mitral Valve Prolapse 326
Miscellaneous Mitral Valve Abnormalities 330
Calcification of the Mitral Annulus 331
Tumors of the Mitral Valve 331
Aneurysms of the Mitral Valve 332
Endocarditis and Valve Perforation 334
Anular Dehiscence 334
Radiation Damage 334
Carcinoid and Diet Drug Valvulopathy 334
Suggested Readings 335
Chapter 13 Tricuspid and Pulmonary Valves 337
Clinical Overview 337
Pulmonary Valve 337
Pulmonary Valve Stenosis 341
Pulmonary Valve Regurgitation 342
Miscellaneous Abnormalities of the Pulmonary Valve 343
Evaluation of the Right Ventricular Outflow Tract 344
Tricuspid Valve 345
Doppler Evaluation of the Tricuspid Valve 346
Tricuspid Stenosis 348
Tricuspid Regurgitation 348
Pacemaker and Catheter-Induced Tricuspid Regurgitation 349
Ischemic Heart Disease 350
Quantitation of Tricuspid Regurgitation 351
Determination of Right Ventricular Systolic Pressure 353
Other Specific Conditions Resulting in Tricuspid and Pulmonary Valve Disease355
Carcinoid Heart Disease 355
Endocardial Fibroelastosis 357
Ebstein Anomaly 357
Tricuspid Valve Resection 357
Cardiac Biopsy 359
Tumors and Other Masses 359
Suggested Readings 359
Chapter 14 Infective Endocarditis 361
Clinical Perspective 361
Echocardiographic Characteristics of Vegetation 361
Diagnostic Accuracy of Echocardiography 366
Evolution of the Diagnostic Criteria 367
Complications of Endocarditis 368
Prognosis and Predicting Risk 374
Prosthetic Valve Endocarditis 375
Infected Intracardiac Devices 377
Right-Sided Endocarditis 378
Approach to the Patient with Endocarditis 379
Suggested Readings 383
Chapter 15 Prosthetic Valves 385
Types of Prosthetic Valves 385
Normal Prosthetic Valve Function 386
Contents ix
Application of Echocardiography to Patients with Prosthetic Valves 392
General Approach to Prosthetic Valves 394
Prosthetic Aortic Valves 397
Prosthetic Mitral Valves 402
Specific Causes of Dysfunction 402
Obstruction 402
Infective Endocarditis 409
Mechanical Failure 415
Right-Sided Prosthetic Valves 415
Valved Conduits 419
Mitral Valve Repair 419
Suggested Readings 424
Chapter 16 Echocardiography and Coronary Artery Disease 427
Clinical Overview 427
Pathophysiology of Coronary Syndromes 427
Detection and Quantitation of Wall Motion Abnormalities 431
Role of the Three-dimensional Echocardiography 436
Doppler Tissue Imaging and Speckle Tracking 437
Other Methods for Evaluating Ischemic Myocardium 438
Echocardiographic Evaluation of Clinical Syndromes 438
Angina Pectoris 438
Acute Myocardial Infarction 438
Natural History of Wall Motion Abnormalities 444
Prognostic Implications 446
Doppler Evaluation of Systolic and Diastolic Function in Acute Myocardial
Infarction 446
Complications of Acute Myocardial Infarction 448
Pericardial Effusion 448
Infarct Expansion/Acute Remodeling 450
Free-Wall Rupture 450
Ventricular Thrombus 451
Right Ventricular Infarction 451
Acute Mitral Regurgitation 453
Ventricular Septal Rupture 455
Cardiogenic Shock 457
Chronic Coronary Artery Disease 457
Left Ventricular Aneurysm 457
Left Ventricular Pseudoaneurysm 460
Chronic Remodeling 462
Mural Thrombus 462
Mitral Regurgitation 464
Chronic Ischemic Dysfunction 465
Direct Coronary Visualization 468
Kawasaki Disease 470
Direct Visualization of Atherosclerosis 470
Suggested Readings 471
Chapter 17 Stress Echocardiography 473
Physiologic Basis 473
Methodology 475
Treadmill 475
Bicycle Ergometry 476
Dobutamine Stress Echocardiography 477
Dipyridamole and Adenosine 478
Three-dimensional Stress Echocardiography 478
Choosing among the Different Stress Modalities 479
Interpretation of Stress Echocardiography 479
Categorization of Wall Motion 482
Wall Motion Response to Stress 484
Localization of Coronary Artery Lesions 484
Correlation with Symptoms and Electrocardiographic Changes 485
x Contents
Detection of Coronary Artery Disease 486
Role of Myocardial Perfusion Imaging 488
Comparison with Nuclear Techniques 491
Applications of Stress Echocardiography 492
Prognostic Value of Stress Echocardiography 492
Stress Echocardiography After Myocardial Infarction 495
Stress Echocardiography After Revascularization 496
Preoperative Risk Assessment 498
Stress Echocardiography in Women 499
Assessment of Myocardial Viability 501
Stress Echocardiography in Valvular Heart Disease 502
Diastolic Stress Echocardiography 503
Suggested Readings 505
Chapter 18 Dilated Cardiomyopathies 507
Clinical and Echocardiographic Overview 507
Dilated Cardiomyopathy 507
Doppler Evaluation of Systolic and Diastolic Function 512
Assessment of Diastolic Function 514
Myocardial Performance Index 516
Secondary Findings in Dilated Cardiomyopathy 517
Etiology of Dilated Cardiomyopathy 518
Determination of Prognosis in Dilated Cardiomyopathy 521
The Role of Echocardiography in Basic and Advanced Therapy 523
Biventricular Pacing for Congestive Heart Failure 523
Cardiac Transplantation and Other Advanced Support 527
Ventricular Assist Devices 530
Myocarditis 534
Peripartum Cardiomyopathy 536
Chagas Myocarditis 536
Suggested Readings 537
Chapter 19 Hypertrophic and Other Cardiomyopathies 539
Overview 539
Hypertrophic Cardiomyopathy 539
Echocardiographic Evaluation of Hypertrophic Cardiomyopathy 539
Assessment of the Left Ventricular Outflow Tract in Obstructive Cardiomyopathy 541
Mitral Regurgitation in Hypertrophic Cardiomyopathy 546
Variants of Hypertrophic Cardiomyopathy 547
Mid-Cavitary Obstruction 548
Screening of Family Members 549
Conditions Mimicking Hypertrophic Cardiomyopathy 550
End-Stage Hypertrophic Cardiomyopathy 553
Hypertrophic Cardiomyopathy Therapy 554
Infiltrative and Restrictive Cardiomyopathy 554
Echocardiographic Evaluation of Restrictive Cardiomyopathy 555
Cardiac Amyloid 556
Restrictive Cardiomyopathy 556
Constrictive Versus Restrictive Heart Disease 556
Endocardial Fibroelastosis and Hypereosinophilic Syndrome 559
Suggested Readings 560
Chapter 20 Congenital Heart Diseases 561
The Echocardiographic Examination: A Segmental Approach to Anatomy 562
Cardiac Situs 562
Ventricular Morphology 563
Great Artery Connections 564
Abnormalities of Right Ventricular Inflow 565
Abnormalities of Left Ventricular Inflow 566
Pulmonary Veins 566
Left Atrium 567
Mitral Valve 570
Contents xi
Abnormalities of Right Ventricular Outflow 571
Right Ventricle 571
Pulmonary Valve 573
Pulmonary Artery 573
Abnormalities of Left Ventricular Outflow 575
Subvalvular Obstruction 576
Valvular Aortic Stenosis 578
Supravalvular Aortic Stenosis 580
Coarctation of the Aorta 581
Abnormalities of Cardiac Septation 584
Atrial Septal Defect 584
Ventricular Septal Defect 590
Endocardial Cushion Defect 600
Abnormal Vascular Connections and Structures 600
Patent Ductus Arteriosus 600
Abnormal Systemic Venous Connections 602
Abnormal Pulmonary Venous Connections 603
Abnormalities of the Coronary Circulation 608
Conotruncal Abnormalities 612
Tetralogy of Fallot 612
Transposition of the Great Arteries 615
Double-Outlet Right Ventricle 621
Persistent Truncus Arteriosus and Aortopulmonary Window 623
Abnormalities of Ventricular Development 623
Single Ventricle 624
Tricuspid Atresia 626
Echocardiographic Evaluation During and After
Surgery 628
Systemic Artery to Pulmonary Artery Shunts 628
The Fontan Procedure 629
Right Ventricle to Pulmonary Artery Conduits 630
Suggested Readings 632
Chapter 21 Diseases of the Aorta 633
Normal Aortic Anatomy 633
Echocardiographic Evaluation 634
Aortic Dilation and Aneurysm 637
Marfan Syndrome 640
Sinus of Valsalva Aneurysm 643
Aortic Dissection 645
Echocardiographic Diagnosis 646
Intramural Hematoma 653
Complications and Natural History of Aortic Dissection 655
Aortic Atheroma 657
Miscellaneous Conditions 661
Coarctation of the Aorta 661
Aortic Pseudoaneurysm 661
Aortic Trauma 661
Infections of the Aorta 662
Aortic Thrombus 663
Takayasu Arteritis 664
Suggested Readings 665
Chapter 22 ICU and Operative/Perioperative Applications 667
Evaluation of Patients in the Medical Intensive
Care Unit 667
Hypotension and Shock 667
Evaluation of Hypoxia 671
Echocardiography in the Emergency Department 671
Echocardiography Following Cardiac Arrest 673
Pre-, Intra-, and Postoperative Echocardiography 673
Role of Echocardiography in Mitral Valve Surgery 676
xii Contents
Tricuspid Valve Repair 687
Role of Echocardiography in Aortic Valve Procedures 687
Miscellaneous Applications 692
Other Intraoperative Complications of Cardiac Surgery 693
Intraoperative Monitoring for Noncardiac Procedures 696
Delayed Cardiac Surgery Complications 696
Monitoring of Nonoperative and Interventional Procedures 698
Interventional Cardiac Procedures 700
Other Applications in the Catheterization Laboratory 708
Suggested Readings 708
Chapter 23 Masses, Tumors, and Source of Embolus 711
Normal Variants and Artifacts: Sources of False-Positive Findings 711
Role of Echocardiography 712
Cardiac Tumors 712
Primary Tumors 712
Metastatic Tumors to the Heart 717
Intracardiac Thrombi 720
Left Ventricular Thrombi 720
Left Atrial Thrombi 726
Right Atrial Thrombi 731
Spontaneous Echo Contrast 731
Role of Echocardiography in Systemic Embolus 732
Pseudotumors and Other Cardiac Masses 736
Suggested Readings 739
Chapter 24 Echocardiography in Systemic Disease and Clinical Problem Solving 741
Echocardiography and Systemic Disease 741
Hypertension 741
Diabetes Mellitus 743
Thyroid Disease 743
Chronic Renal Insufficiency 744
Connective Tissue/Autoimmune Disease 746
Systemic Lupus Erythematosus 746
Antiphospholipid Antibody Syndrome 747
Scleroderma/Raynaud Phenomenon 747
Marfan Syndrome 748
Chronic Liver Disease and Cirrhosis 750
Chronic Obstructive Pulmonary Disease 752
Pulmonary Hypertension 753
Miscellaneous Diseases 757
Sarcoidosis 757
Hemochromatosis 758
Muscular Dystrophy/Glycogen Storage Disease 758
Hypereosinophilia 758
Carcinoid Syndrome 759
Sickle Cell Anemia 759
Human Immunodeficiency Virus 759
Diet-Drug Valvulopathy 760
Obesity 760
Clinical Presentations and Problem Solving 760
Congestive Heart Failure 760
Evaluation of Dyspnea 761
Acute Pulmonary Embolus 762
Echocardiographic Findings 762
Atrial Fibrillation 763
Neurogenic Myocardial Stunning 766
Syncope 767
Evaluation of Cardiac Arrhythmias 767
Evaluation of Patients Before and During Chemotherapy 768
Radiation-Induced Cardiac Disease 768
Screening for Athletic Competition and the Athlete’s Heart 769
Contents xiii
The Heart in Pregnancy 770
Effects of Advanced Age 772
Suggested Readings 773
INDEX 77