MODULE 16

STRESS ECHO CARDIOGRAPHY

Overview 16-3
Objective 16-3
Purpose 16-3
Instructions 16-3
Defining Stress Echo Cardiography 16-4
Introduction 16-4
Exercise Stress Echo 16-4
Pharmacological Stress Echo 16-4
Staged Protocol 16-4
Recalling Stress Echo 16-4
Exercise Stress Program 16-5
Preset Exercise Stress Program 16-5
Comparing Stages by View 16-5
Pharmacological Stress Program 16-6
Preset Pharmacologic Stress Program 16-6
Comparing by View or Stage 16-7
How Does It Work? 16-8
Introduction 16-8
Normal ECG 16-8
A Twelve-lead ECG 16-8
Acquiring View Clips 16-10
ECG Signal Path 16-10
Stress Echo and Sequoia Systems 16-11
Stress Echo and Aspen Systems 16-12
Connecting the ECG from OEMs 16-13
Introduction 16-13
Setting Up ECG Input from an OEM 16-13
Black Box Solution 16-14
Acuson Cable Solution 1 16-14
Acuson Cable Solution 2 16-15
Miscellaneous 16-15
Typical Stress Echo Problems and Solutions 16-16
Common Problems 16-16
Stress Echo Symptoms 16-16
Worksheet: Stress Echo 16-18
Module 16 - Stress Echo Cardiography Acuson Confidential

REVISION HISTORY

QRC P/N-REVISION INITIATOR APPROVAL DATE CHANGE

S. Williams July 1999 Incorporate reviewer comments

A3175 P/N 63328 Rev. 1 J. Madarasz S. Williams Dec. 2000 Initial Release

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Acuson Confidential Overview

OVERVIEW
OBJECTIVE To understand the basics of stress echo including its uses.
To hook up an Acuson system to various OEM machines.
To verify its functionality, and troubleshooting.

PURPOSE Stress echo cardiography is available as an option to all cardiology

customers as a built-in package with Sequoia C256, Sequoia 512
shared service, and Aspen systems.

INSTRUCTIONS 1 Listen to the presentation.

2 Observe the demo, specifically on how to verify functionality.
3 Listen to the presentation on signal flow, OEM interfacing, and
typical problems.

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Module 16 - Stress Echo Cardiography Acuson Confidential

DEFINING STRESS ECHO CARDIOGRAPHY

INTRODUCTION Stress echo cardiography (stress echo) is a very effective tool in
diagnosing cardiac problems. Typical indications for the use of
stress echo include chest pain and/or pressure, clinical assessment
of post Myocardial Infarction (MI), Coronary Arterial Bypass Graft
(CABG), and angioplasty. It is sometimes also used for pre-
operative clearance for non-cardiac surgical procedures. Stress Echo
can be used in two ways:
Exercise Stress Echo
Pharmacological Stress Echo

EXERCISE STRESS In this type of stress echo, the patient is attached to a twelve-lead
ECHO ECG machine, such as one by Quinton or Marquette. The patient
then exercises on a treadmill or exercise bicycle to increase the heart
rate. When the peak heart rate is reached, the patient quickly lies
down and is immediately scanned. The images must be obtained
within next ninety seconds.

PHARMACOLOGICAL In pharmacological stress echo, the heart rate is elevated not by

STRESS ECHO exercise, but by medication. This type of stress echo is used when
the patient cannot exercise. The two drugs most commonly used for
this are Dobutamine and Arbutamine. These drugs are infused
during a multi-stage protocol until peak heart rate is reached. The
patient is then scanned immediately.

STAGED PROTOCOL A staged protocol can be used to perform exams that have a set
protocol or sequence, such as an exercise or pharmacological stress
exam. Images are acquired with the capture settings of each stage,
proceeding one stage at a time. For details on how to customize the
AEGIS system setup for a staged protocol, refer to the Sequoia
Reference Manual.

RECALLING STRESS
ECHO
To recall the stress echo program:
1 Press the PROGRAM key on the user interface.
2 Use the trackball to select EXERCISE STRESS or PHARM STRESS,
depending on the application used.

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Acuson Confidential Exercise Stress Program

EXERCISE STRESS PROGRAM

Refer to Using AEGIS Stress Echo in the Sequoia Reference Manual
for more detailed information.
The exercise stress program consists of three stages:
Rest
Immediate Post (^HR)
Immediate Post (vHR)
If the patients heart rate exceeds 140 beats per minute (bpm)
during the exam, then ImPost (^HR) is used as it has shorter
segment length (280 msec versus 400msec).

PRESET EXERCISE
STRESS PROGRAM
ITEM REST IMPOST^HR IMPOSTVHR
Playback speed 50% 50% 50%
Playback mode loop align loop align loop align
Frm Rate 30 Hz 30 Hz 30 Hz
Clip Size ROI ROI ROI
Clip/Capture 4 full disclosure full disclosure
Seg/Clip 1 1 1
Seg length 400 msec 280 msec 400 msec
Display Stg Timer off on on
Save on capture off off off
Auto review on off off
Auto-delete on on on
Enable Trig on on on
Trig Delay 0 msec 0 msec 0 msec

COMPARING STAGES
BY VIEW

To compare stages by view:

1 Press [STAGE/VIEW] and highlight VIEW. This displays the final page
of the exam (A4C and A2C views side-by-side).
2 Press PG UP to see the PLAX and PSAX comparisons.
3 The images play back in loop align more. Turn FREEZE/RUN wheel
to change the playback speed of all the clips simultaneously. It is
reflected as a percentage speed in the data field.

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Module 16 - Stress Echo Cardiography Acuson Confidential

PHARMACOLOGICAL STRESS PROGRAM

Refer to Using AEGIS Stress Echo in the Sequoia Reference Manual
for more detailed information.
The pharmacological stress program consists of seven stages:
Baseline
Low Dose
20 mcg
30 mcg
40 mcg + atropine
Peak Stage
Recovery
Typically, users select the Baseline, a Low Dose stage, Peak stage
(varies with patient response), and Recovery.

PRESET
PHARMACOLOGIC
STRESS PROGRAM
ITEM BASEL LOW 20 30 40 MCG + RECOVER
INE DOSE MCG MCG ATROPINE Y
Playback speed 50% 50% 50% 50% 50% 50%
Playback mode loop loop loop loop loop align loop align
align align align align
Frm Rate 30 Hz 30 Hz 30 Hz 30 Hz 30 Hz 30 Hz
Clip Size ROI ROI ROI ROI ROI ROI
Clip/Capture 4 4 4 4 4 4
Seg/Clip 1 1 1 1 1 1
Seg length 400 400 400 400 360 msec 400 msec
msec msec msec msec
Display Stg Timer off on on on on off
Save on capture off off off off off off
Auto review on on off off off off
Auto-delete on on on on on on
Enable Trig on on on on on on
Trig Delay 0 msec 0 msec 0 msec 0 msec 0 msec 0 msec

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Acuson Confidential Pharmacological Stress Program

COMPARING BY VIEW
OR STAGE

To compare by view or stage:

1 Press [STAGE/VIEW] and highlight VIEW.
2 Press [SHOW ALL/SELECTED] and highlight selected. The view
selected for the four stages that were selected appear.
3 Review by View, which will display all the PLAX on one page, and
so on for each view. Also review the images by Stage This selection
displays all the Baseline images together, and so on for each Stage.

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Module 16 - Stress Echo Cardiography Acuson Confidential

HOW DOES IT WORK?

INTRODUCTION During a stress echo cardiography (stress echo) exam, the
sonographer stores clips of several views of the heart in various
stages of rest and activity, under a stress echo protocol in the AEGIS
system. Wall motion scoring is used to analyze the completed stress
echo exam. The stored clips are displayed while scoring is
performed; once the views for each stage are scored, the calculation
results in the cardiac calculation report can be reviewed.

NORMAL ECG The electrocardiogram (ECG) is a recording of electrical activity in

the heart during contractions. Figure 16-1 shows a normal ECG
pulse.

P T

Q S
Figure 16-1 Normal ECG Pulse
The normal ECG pulse consists of five waves or deflections, which
represent an electrical wave as it moves through the heart.
P Wave - spread of excitation wave over atria
QRS Complex - spread of excitation wave over the ventricles
T Wave - electrical recovery and relaxation of the ventricles

A TWELVE-LEAD To acquire a twelve-lead ECG, electrodes are placed on designated

ECG areas of the patients body and, by the use of a combination of these
electrodes, twelve different views of the same electrical activity
appear on the ECG display. Each view of the heart is called an ECG
lead. In stress echo, a diagnostic twelve-lead ECG is used. This lead
consists of three standard leads, three augmented leads, and six
precordial leads. The precordial leads view the heart in the
horizontal plane. See Figure 16-2, Figure 16-3 and Figure 16-4.

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Acuson Confidential How Does It Work?

- + - -

+ +
Lead I Lead II Lead III Einthovans
Triangle

Figure 16-2 Standard Leads

+
+ + + -
- - +

Lead AVR Lead AVL Lead AVF

Figure 16-3 Augmented Leads

1 2

34 56

Figure 16-4 Precordial Leads

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Module 16 - Stress Echo Cardiography Acuson Confidential

ACQUIRING VIEW Dynamic clips are acquired for each stage, proceeding one stage at a
CLIPS time. The acquisition of dynamic clips is triggered by the presence
of an R-wave in the patients ECG. Figure 16-5 illustrates the R-
wave detection.

ECG signal Rectified signal R-wave Detection

Figure 16-5 R-Wave Detection

ECG SIGNAL PATH The ECG input is provided by the standard ECG cable or via DC-A
input on the FIZ module for Sequoia systems and to the ECG2 on
the Aspen system. Figure 16-6 illustrates the FIZ or ECG2 module.
The analog ECG signal is amplified and processed within the
module, providing the following two outputs:
ECG Signal - digital data stream
R Trigger - single wave (single bit)

ECG Input R-Trigger

Interrupt
ECG data
DC-A MUX ADC DSP

DAC
DC-D

FIZ or ECG2 Module

Figure 16-6 FIZ or ECG2 module

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Acuson Confidential How Does It Work?

STRESS ECHO AND The outputs from the FIZ module are routed via a single cable
SEQUOIA SYSTEMS assembly to the PIC board. From the PIC board, these signals are
routed via the backplane to separate destinations. The digital data
stream is routed to the SDM memory on the BDM board. After
BDM, this signal is processed and overlaid on the 2-D image for
display.
The R-trigger signal is a one-bit interrupt, which is routed via the
PIC board and the backplane to the IOP on the IOV board. The IOP
generates an inter-processor communication to the ACP on the CN
board to trigger acquisition of the dynamic clip. The dynamic clips
are initially stored on the SDM memory block and then transferred
to the internal hard disk. Figure 16-7 illustrates the ECG signal path
in a Sequoia system.

LA RA

BP PIC
RL
BDM
CPP WGP BAP

SDM

IRB VDB SMM

.....
Text & IOV SDM
FIZ
Static Video-
SSP
Graphics Standard Data

IOP

CN
ACP

Hard
BBF
Disk
FCP
MO
IOE Disk
ECG Signal
R-Trigger
JPEG
AEGIS Archive
Figure 16-7 ECG signal path in Sequoia systems

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Module 16 - Stress Echo Cardiography Acuson Confidential

STRESS ECHO AND The outputs from the ECG2 module are routed via a single ribbon
ASPEN SYSTEMS cable to the WFP board. This Physio interface cable contains the
signal and status lines. These signals include ECG wave, auxiliary
wave, and trigger signals. At the WFP board, the analog trace data
is D/A converted and R-wave detected.
The R-wave detection triggers the WFP to generate an interrupt
signal to the RP board to trigger the acquisition of the dynamic clip
to the CDM board. The acquired clips are later stored on to the
internal hard disk for storage. The WFP uses the digitized data to
reconstruct the waveforms on the video monitor. Figure 16-8
illustrates the ECG signal path in an Aspen system.

LA RA

RL

ACP RP WFP
ADC
ECG2

.....

CDM
IOB

ECG Signal
R- Trigger
AEGIS Archive
DCI
SVC VPB

JPEG

Figure 16-8 ECG Signal Path in the Aspen System

Module 16-12 Service Training Manual P/N 63328 Rev. 1

Acuson Confidential Connecting the ECG from OEMs

CONNECTING THE ECG FROM OEMS

INTRODUCTION To conduct stress echo examinations, the customer may want to use
the ECG input from an OEM equipment. These OEMs include
Marquette and Quinton products. The list of some of the OEM
models that are used with Acuson echo cardiography systems to
conduct stress echo examinations include:
Quinton 4000, 4500, and 5000
Marquette Case 12, 15, 16, and Centra
Marquette Max 1 and Max Personal

SETTING UP ECG Figure 16-9 shows the typical setup for setting up stress echo using
INPUT FROM AN OEM the ECG input from an OEM device.

TomTec
Attenuator Box

ECG Input on FIZ

DC-A Input on FIZ

Host
Interface Cable

Acquisition
Marquette ..... Module
or
Quinton

Acquisition Module:
AM3, AM4, and AM5
Figure 16-9 Stress Echo Setup Using ECG Input from OEM

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Module 16 - Stress Echo Cardiography Acuson Confidential

BLACK BOX This interface uses a TomTec attenuator or Black box to connect the
SOLUTION Acuson ultrasound system with the OEMs providing ECG input.
Use the Gold Audio/ Video dubbing cable RS P/N 15-1520.
Additional cables required are mentioned below for each OEM
product:

OEM PRODUCT PART NUMBER FUNCTION

Quinton 4000, 4500 RS P/N 274-378 Phono jack to mini

stereo plug adaptor

Marquette case 12, 15, 16, and RS P/N 278-254 Phono jack to BNC plug
Centra

Marquette Max 1/Max Personal From Marquette 9-pin D-connector

or hospital

ACUSON CABLE This interface uses cables provided by Acuson. The ECG signal is
SOLUTION 1 input into the ECG port on the FIZ module. Use the 1/4 phono
male to ECG six-pin male cable, Acuson P/N 35174 and the 1/4
phono male/female extension cable, Acuson P/N 35175.
Additional cables required are mentioned below for each OEM
product:

OEM PRODUCT PART NUMBER FUNCTION

Quinton 4000, 4500 RS P/N 274-047C Phono jack to mini

stereo plug adaptor

Marquette case 12, 15, 16, and RS P/N 278-254 Phono jack to BNC plug
Centra RS P/N 274-389B Phono plug to phono
jack

Marquette Max 1/Max Personal From Marquette 9-pin D-connector

or hospital

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Acuson Confidential Connecting the ECG from OEMs

ACUSON CABLE This interface uses cables provided by Acuson. The ECG signal is
SOLUTION 2 input into the DC-A port on the FIZ module. The QRS source must
be reassigned in order to trigger from the R-wave. Use the 1/4
phono male/male cable, Acuson P/N 24604 and the 1/4 phono
male/female extension cable, Acuson P/N 35175.
Additional cables required are mentioned below for each OEM
product:

OEM PRODUCT PART NUMBER FUNCTION

Quinton 4000, 4500 RS P/N 274-047C Phono jack to mini

stereo plug adaptor

Marquette case 12, 15, 16, and RS P/N 278-254 Phono jack to BNC plug
Centra
RS P/N 274-389B Phono plug to phono
jack

Marquette Max 1/Max Personal From Marquette 9-pin D-connector

or hospital

MISCELLANEOUS R-wave trigger out is always present at the DC-D port. This may be
used to trigger off-line acquisition system (i.e., TomTec or Nova).

NOTE: The DC-A port on the FIZ or ECG2 modules can be used to slave from
any external ECG monitor. However, the QRS source must be
reassigned in order to trigger for AEGIS clips.

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 Module 16 - Stress Echo Cardiography Acuson Confidential

TYPICAL STRESS ECHO PROBLEMS AND SOLUTIONS

COMMON PROBLEMS Some of the common problems faced during stress echo
examinations include the following:
Electrodes out of date and dehydrated
Poor contact caused by excessive sweating after exercise
Poor signal caused by lead positioning or pathology
Incorrect assignment for the QRS source

STRESS ECHO The following chart shows typical symptoms/problems reported

SYMPTOMS from stress echo examination and the recommended action to take.

SYMPTOMS ACTION TAKEN

QRS signal weak, increasing the ECG gain does The ECG gain only changes the size of the display
not make any difference and does not affect the signal

QRS signal ok on Sequoia system, but unable to ECG Lead positions corrected to resolve the issue.
trigger intermittently Lead II is recommended.

Flat ECG on display and no capture Restart Physio to recover ECG trace
QRS source reassigned to DC-A and resolved the
problem

Playback speed of Stress Echo too fast Corrected Setup to capture one beat

Improper trigger or triggering on P or T-waves Capture triggering on other waves than R-wave.
Corrected ECG Lead positions.

Intermittent lock-ups or error messages while Try clearing the AEGIS data. Make sure to back up
doing Stress Echo examination from previously backed up data

RF interference on the image/ NTHI images Sometimes caused by interference from OEM
devices. See the following page for the solutions to
the problem, based on the configuration used.

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Acuson Confidential
SYMPTOMS
Marquette
If a Sequoia system is going to experience the
RFI problem with Marquette, it will begin after
NTHI has been installed, when Stress Echo
exams are done, and when using the 3V2 or
5V3. The noise will not occur otherwise. If
noise is seen under other circumstances, look
for other sources of the noise.
Max 1 model is used with AM4
Case 12 or 15 is used with AM4
Case 16 is used with AM4
To obtain the above mentioned cables, CE must call Marquette Customer Service Center at
1-800-558-5120, order the appropriate cable on credit card, and expense it on the expense report.
Typical cost of the cables is about $60.
Quinton 4500 only
If the customer reports noise problems with
other Quinton models (4000 or 5000), look for
other root causes of the noise, i.e. noise on the
input power, other sources of RFI. There are no
known problems with the other models.
P/N 63328 Rev. 1 Service Training Manual
Typical Stress Echo Problems and Solutions
ACTION TAKEN
The Acquisition Module (AM) can be a source of RFI
noise in the Marquette Stress Echo system. The FAS
may call it a Treadmill but there will typically be
three items in the system -- a Treadmill, a control
unit, and the Acquisition Module (AM). The AM is
the box that straps to the patient and has the ECG
leads plugged into it. There is a cable that connects
the AM to the control unit. An older version of this
cable can pick up the RFI noise from the AM and
then it will display in the Aspen or Sequoia system
image. This noise is in the 3MHz to 5MHz range so
will only show up on the lower frequency
transducers. Marquette has developed a fully
shielded cable which will reduce the noise and, in
some cases, eliminate it. They have only developed
the cable for a few control unit types and for the
AM4. The control units are the MAX1, Case 12, Case
15, and Case 16. If the customer has an AM3 we can
recommend that the customer upgrade to the AM4
or AM5. AM5 has been designed so that it doesnt
radiate. If the cable is the fully shielded version and
the noise still occurs, look for other sources of the
noise.
Host Interface cable required- p/n 700044-201
Host Interface cable required- p/n 700044-202
Host Interface cable required- p/n 700044-204
The Quinton 4500 has a known pre-amp problem
that can cause noise in the image on XP, Aspen, and
Sequoia systems. Quinton will install a free warranty
upgrade of the pre-amp once the customer calls
Quinton to report the problem (1-800-426-0538
between 3:30 am and 4:30 pm PST). It is important
that the customer calls to report the problem because
Quinton is tracking their configurations and any
upgrades they do.
Module 16- 17
 Module 16 - Stress Echo Cardiography Acuson Confidential

WORKSHEET: STRESS ECHO

LAB OBJECTIVE NOTES SIGN OFF

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