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Principles of Echocardiography

CONTENTS
10

Physics of Ultrasound

11

2D Images

13

Artefacts

15

Optimizing 2D Images

15

MMode

16

Spectral Doppler

17

Flow Dynamics

18

Color Doppler

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NOTES
The higher the ultrasound

PHYSICS OF ULTRASOUND
Ultrasound Wave

frequency, the better the

resolution. However, you lose
penetration.

Wave propagation occurs through

The velocity of ultrasound is 1540 m/s in

compression and decompression of

tissue and 1570 m/s in blood.

tissue.

Medical Ultrasound
Frequencies between 2 10 MHz are used.

SEND

RECEIVE

Alternating current applied to piezoelec-

Received ultrasound waves (echoes)

tric crystals generates ultrasound waves..

cause the piezoelectric crystals to

generate an electric signal which is
transformed into an image..

Diagnostic ultrasound

Safety of Ultrasound

has no adverse effects.

Physical effects of ultrasound:

Thermal effect (depends on US intensity)
Cavitations

The higher the pulse

Ultrasound Pulse

repetition frequency, the

higher the frame rate and
image resolution.

Pulse

Pulse repetition period

The higher the US frequency, the higher the pulse repetition frequency.

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2D IMAGE

NOTES

2D Image

Ultrasound is a cut-plane
technique. Several elements
are used to generate a 2D
image.

Types of Probes

In echocardiography we use
curvilinear probes. The
advantage of such probes is
their small footprint. Thus,
it is easier to image from
small intercostal spaces.
Image quality increases with
higher scan line densities.

Image Quality
What determines overall resolution?
Spatial resolution lateral

Contrast resolution

Spatial resolution axial

Temporal resolution

Determinants of Spatial Resolution

Lateral resolution

Axial resolution

Beam width/line density

Ultrasound frequency

Ultrasound frequency

Pulse repitition frequency

Gain

Gray

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NOTES
Harmonic imaging

2D IMAGE
Harmonic Imaging

uses the resonance

characteristics of
tissue. The advantage
is less artefacts,
improved spatial and
contrast resolution,

SEND

RECEIVE

leading to better
image quality.

Legend: The signal returned by tissue includes the transmitted

fundamental frequency as well as signals of other frequencies. In harmonic imaging one uses those frequencies that are a multiple (harmonic) of the fundamental
(sending) frequency.

Aim for high frame

Frame Rate Influence

rates. They allow the

study of rapid motion

The frame rate describes the number of frames/sec that are displayed.

when using the image

Frame rate depends on:

review function.
Sector width

Frequency

Scan lines

Depth

Limitations of 2D Imaging
Attenuation
Tissue properties (fibrosis, calcification)

Limited penetration (obesity, narrow

imaging window)

Artefacts

Attenuation
Definition: Decrease in amplitude and intensity as the ultrasound wave travels
through a medium
Attenuation may be caused by:
Absorption (proportional to frequency)

Reflection

Refraction

Shadowing

Transfer of energy from the

Pseudoenhancement

beam to tissue

Enemies of Ultrasound
Air (reflection of ultrasound) and bone (absorption of ultrasound)
In both conditions you cannot see what is behind.

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ARTEFACTS

NOTES

Types of Artefacts

Imaging is difficult in patients

with small intercostal spaces

Near field clutter

Side lobe artefact

(bone) and in patients

Reverberation

Beam width artefacts

with COPD (air).

Acoustic shadowing

Attenuation artefacts

Mirror imaging/double images (caused by refraction)

REVERBERATION
apical four-chamber view/2D
Highly echogenic pericardium
leading to reverbations

Specific Forms
Side lobes

Reverberation

Main lobe

Side
lobe

Side lobes usually occur at strong

Reverberation occurs when the echo

reflectors (e.g. prosthetic material). Power

bounces back and forth several times

density is higher in the central beam than

sometimes between a structure and

in side lobes. This may lead to the edge

the surface of the transducer.

effect, which makes structures appear

wider than they actually are.

Beam width artefact

US beam

Beam width artefacts occur

when the beam width is wide
Image

and unfocused.
Wide

Narrow
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NOTES

ARTEFACTS

GAIN SETTINGS PSAX/2D

Different gain settings in the
same patient. Structures are
missed when gain settings are
too low (upper left). Delineation
of different gray scales (tissue
characteristics) is impaired when
the gain is set to high
(lower right).

Artefacts are

When Do Artefacts Occur?

inconsistent.
Good image quality (e.g. mirror artefacts) Strong reflectors (e.g. calcification,
Poor image quality

prosthetic material)
More frequent in fundamental imaging

ARTEFACT IN PROSTHETIC VALVE

apical four-chamber view/2D
Shadowing and reverberations of
the left atrium caused by a mechanical mitral valve prosthesis.

Tips to Avoid Artefacts

14

Know the pitfalls

Be cautious of strong reflections

Know the anatomy

Use multiple views

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OPTIMIZING THE 2D IMAGE

Important Settings

NOTES
Know your echo

Gain

Depth

Time gain compensation (TGC)

Imaging frequency

Sector width

Focus

Post-Processing

machine!

Use predefined settings for

specific situations (i.e. patients

Gray scale

Compression

who are difficult to examine)

Contrast

Color maps

and for specific modalities (i.e.

standard echo, contrast).
COLOR MAPS PSAX/2D
Different 2D color maps for
individualized 2D display.

MMODE
MMode

MMode has lost much of its

importance, but is still

Advantage

Where is it used?

High temporal resolution

Aorta/left atrium (measurements,

Good for certain measurements

valuable in certain situations.

opening of the aortic valve)

Allows measurement of time intervals

Timing of events

Left/right ventricle (measurements,

LV function)
Mitral/prosthetic valve (type of valve)
Endocarditis (motion of suspected
vegetation)
Tricuspid annular plane systolic
excursion (TAPSE) for RV function

RV
IVS

Mitral valve (mitral stenosis)

Mitral valve annular excursion (MAPSE)
for longitudinal LV function

Post.
wall
Diastole Systole

Display of mid-systolic notching

(flying W) of the posterior pulmonary
valve cusp

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NOTES

MMODE
Other Forms of MMode
Anatomical MMode

Freedom of axis
Anatomical MMode

Color Doppler MMode

Timing of flow (i.e. flow

propagation)

Tissue Doppler MMode

Myocardial function,
timing of events

Curved MMode

Functional information along

Conventional MMode

a variable MMode line

SPECTRAL DOPPLER
The measured velocity

Doppler Formula

greatly depends on the angle

between blood flow and the
ultrasound beam. Always try
to be as parallel to blood
flow as possible. Use color

v cos"
!d = 2!f
c 0
!d = frequency alteration between

The Doppler formula allows us

Doppler to visualize the

S and E (=Doppler shift)(Hz)

direction of flow.

f0 = transmitting frequency (Hz)

blood and tissue), based on

v = blood flow (m/s)

the Doppler shift between the

c = sound propagation

send and the receive signal.

to calculate velocities (i.e.

velocity (1550 m/s)

" = Doppler irradiation angle

Doppler

Aliasing will occur when blood

Pulsed wave (PW) Doppler

Low velocity (< approx. 1.5 m/s) (site specific)

Continous wave (CW) Doppler

High velocity (> approx. 1.5 m/s) (site unspecific)

Tissue Doppler

Lower velocity, higher amplitdue

Doppler Aliasing

flow velocity exceeds the

Nyquist limit. The Nyquist limit

Depends on

is equal to a half of the pulse

Depth

Width of sample volume

repetition frequency. Use the

Velocity

Doppler frequency

baseline shift to stretch the

Nyquist limit.

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SPECTRAL DOPPLER

NOTES
PW DOPPLER ALIASING apical
four-chamber view/PW MV
Pulsed-wave Doppler in a patient
with mitral stenosis. The maximum velocity exceeds 2.5 m/s
and exceeds the aliasing limit.
Velocity profiles are noted both
above and below the zero line.

Tissue Doppler Imaging

Tissue Doppler is
angle dependent.

Information
Myocardial velocity

Strain

PW spectral tissue Doppler

Displacement

Strain rate

measures deformation and

velocities at a specific site
(within the sample volume).
TISSUE DOPPLER apical
four-chamber view
Tissue Doppler color display of
the heart during early systole.
Red indicates myocardial motion
towards the transducer.

FLOW DYNAMICS
Bernoulli Equation
The simplified Bernoulli equation permits
easy estimation of pressure gradients

P(mmHg)

from velocities.
V(m/s)

P = 4xV2

P(mmHg)

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NOTES

FLOW DYNAMICS
Where Can You Apply the Bernoulli
Equation in the Heart?
Direct applications (gradients)

Indirect applications (pressure decay)

Valvular stenosis

Aortic regurgitation quantification

Defects (i.e. VSD, coarctation, PDA)

Diastolic function (deceleration time)

Tricuspid regurgitation signal (sPAP)

dP/dt (contractility)

Prosthetic valves

Mitral stenosis (pressure half-time method)

Sites where Gradients can be measured.

COLOR DOPPLER
The manner of displaying

Color Encoding

flow, flow velocities or

turbulant flow is determined
by the color map. Most

Flow towards the transducer is coded in red, and flow away

from the transducer in blue.

scanners allow you to

change the color map.
Check your machine setings.
towards

away

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+ 62 m/s

- 62 m/s

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COLOR DOPPLER

NOTES

Color Doppler and Aliasing

The phenomenon of
aliasing provides good

Once the Nyquist limit is reached, the color changes abruptly

delineation of jets

(red to blue, or blue to red). The color Doppler display will show

(e.g. PISA).

a mosaic pattern. Some color maps also display variants of velocity

in green (high variants in velocities indicate turbulent flow).

Flow towards the transducer

lower velocity

turbulant/high velocity
flow green

Aliasing border
(from orange to blue)

Flow towards
the transducer higher
velocity (orange)

COLOR DOPPLER ALIASING

apical four-chamber view/
Color Doppler
Patient with mitral stenosis. The
color Doppler of mitral valve
inflow shows the typical pattern
of a high velocity jet. Red color
denotes the direction of flow
towards the transducer. The sudden change from yellow to blue
depicts the region where aliasing
occurs.

Flow towards the

transducer
low velocity (red)

Color Doppler Frame Rate

Always aim for a high color

Doppler frame rate.

Scan line density

Emphasis (2D vs. color)

Try to use the same settings for

Sector width (2D)

quantification of regurgitation in

Sector width (color)

all patients (maps, aliasing limits,

Pulse repetition frequency

color gain).

Depth

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NOTES

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