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An echocardiography, echocardiogram, cardiac echo or simply an echo, is an
ultrasound Ultrasound is s with higher than the upper audible limit of human . Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies from person to person and is appro ...

ultrasound
of the
heart The heart is a cardiac muscle, muscular Organ (biology), organ in most animals, which pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste ...

heart
. It is a type of
medical imaging Medical imaging is the technique and process of imaging Imaging is the representation or reproduction of an object's form; especially a visual representation (i.e., the formation of an image). Imaging technology is the application of materi ...
of the heart, using standard ultrasound or
Doppler ultrasound Doppler ultrasonography is medical ultrasonography Medical ultrasound (also known as diagnostic sonography or ultrasonography) is a medical imaging, diagnostic imaging technique, or therapeutic ultrasound, therapeutic application of ultrasound ...
. Echocardiography has become routinely used in the diagnosis, management, and follow-up of patients with any suspected or known
heart disease Cardiovascular disease (CVD) is a class of diseases that involve the heart The heart is a cardiac muscle, muscular Organ (biology), organ in most animals, which pumps blood through the blood vessels of the circulatory system. The pumped b ...
s. It is one of the most widely used diagnostic imaging modality in cardiology. It can provide a wealth of helpful information, including the size and shape of the heart (internal chamber size quantification), pumping capacity, and the location and extent of any tissue damage, assessment of valves and cardiac masses. An echocardiogram can also give physicians other estimates of heart function, such as a calculation of the
cardiac output Cardiac output (CO), also known as heart output denoted by the symbols Q, or \dot Q_ , is a term used in cardiac physiologyCardiac physiology or heart function is the study of healthy, unimpaired function of the heart: involving blood flow; Ca ...
,
ejection fraction An ejection fraction (EF) is the volumetric fraction A fraction (from Latin ', "broken") represents a part of a whole or, more generally, any number of equal parts. When spoken in everyday English, a fraction describes how many parts of a certa ...
, and
diastolic Image:Heart diastole.png, upright=1.5, Heart performance during ventricular diastole: early diastole is a suction mechanism that draws blood 'down' from the left atrium (pink) and right atrium (blue) into each of the two ventricles. Then, in late ve ...
function (how well the heart relaxes). Echocardiography is an important tool in assessing wall motion abnormality in patients with suspected cardiac disease. It is a tool which helps in reaching an early diagnosis of
myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow Hemodynamics American and British English spelling differences#ae and oe, or haemodynamics are the Fluid dynamics, dynamics of blood flow. The circulatory sy ...

myocardial infarction
showing regional wall motion abnormality of the heart. Also, it is important in treatment and followup in patients with
heart failure Heart failure (HF), also known as congestive heart failure (CHF) and (congestive) cardiac failure (CCF), is a Syndrome, set of manifestations caused by the failure of the heart's function as a pump supporting the Circulatory system, blood flow t ...
, by assessing
ejection fraction An ejection fraction (EF) is the volumetric fraction A fraction (from Latin ', "broken") represents a part of a whole or, more generally, any number of equal parts. When spoken in everyday English, a fraction describes how many parts of a certa ...
. Echocardiography can help detect cardiomyopathies, such as
hypertrophic cardiomyopathy Hypertrophic cardiomyopathy (HCM) is a condition in which the heart becomes hypertrophy, thickened without an obvious cause. The parts of the heart most commonly affected are the interventricular septum and the ventricles. This results in the hea ...
, dilated cardiomyopathy, and many others. The use of stress echocardiography may also help determine whether any chest pain or associated symptoms are related to heart disease. The biggest advantage of echocardiography is that it is not invasive (does not involve breaking the skin or entering body cavities) and has no known risks or side effects. Not only can an echocardiogram create ultrasound images of heart structures, but it can also produce accurate assessment of the blood flowing through the heart by Doppler echocardiography, using pulsed- or continuous-wave Doppler ultrasound. This allows assessment of both normal and abnormal blood flow through the heart. Color Doppler, as well as spectral Doppler, is used to visualize any abnormal communications between the left and right sides of the heart, any leaking of blood through the valves (valvular regurgitation), and estimate how well the valves open (or do not open in the case of valvular stenosis). The Doppler technique can also be used for tissue motion and velocity measurement, by
tissue Doppler echocardiography Tissue Doppler echocardiography (TDE) is a medical ultrasound technology, specifically a form of echocardiography that measures the velocity of the heart muscle (cardiac muscle, myocardium) through the phases of one or more heartbeats by the Dopple ...
. Echocardiography was also the first ultrasound subspecialty to use intravenous contrast. Echocardiography is performed by cardiac sonographers, cardiac physiologists (UK), or physicians trained in echocardiography. Recognized as the "Father of Echocardiography", the Swedish physician
Inge Edler Inge Gudmar Edler (17 March 1911 – 6 March 2001) was a Swedish cardiologist, who in collaboration with Carl Hellmuth Hertz developed medical ultrasonography Medical ultrasound (also known as diagnostic sonography or ultrasonography) is a m ...
(1911-2001), a graduate of
Lund University Lund University ( sv, Lunds universitet) is a Public university, public research university in Sweden and one of northern Europe's oldest universities. The university is located in the city of Lund in the province of Scania, Sweden. It traces its r ...
, was the first of his profession to apply ultrasonic pulse echo imaging in diagnosing cardiac disease, which the acoustical physicist Floyd Firestone had developed to detect defects in metal castings. In fact, Edler in 1953 produced the first echocardiographs using an industrial Firestone-Sperry Ultrasonic Reflectoscope. In developing echocardiography, Edler worked with the physicist
Carl Hellmuth Hertz Carl Hellmuth Hertz (also written Carl Helmut Hertz, October 15, 1920 – April 29, 1990) was a German physicist known primarily for being involved in the development of inkjet technology and ultrasound technology. He was the son of Gustav Ludwi ...
, the son of the
Nobel laureate Nobel laureates of 2012 Alvin E. Roth, Brian Kobilka, Robert J. Lefkowitz">Brian_Kobilka.html" ;"title="Alvin E. Roth, Brian Kobilka">Alvin E. Roth, Brian Kobilka, Robert J. Lefkowitz, David J. Wineland, and Serge Haroche during the ceremony Th ...
Gustav Hertz Gustav Ludwig Hertz (; 22 July 1887 – 30 October 1975) was a German experimental physicistExperimental physics is the category of disciplines and sub-disciplines in the field of physics Physics (from grc, φυσική (ἐπιστήμ ...

Gustav Hertz
and grandnephew of
Heinrich Rudolph Hertz Heinrich Rudolf Hertz ( ; ; 22 February 1857 – 1 January 1894) was a German physicist A physicist is a scientist A scientist is a person who conducts Scientific method, scientific research to advance knowledge in an Branches of scien ...
.


Medical uses

Health societies recommend the use of echocardiography for initial diagnosis when a change in the patient's clinical status occurs and when new data from an echocardiogram would result in the physician changing the patient's care. Health societies do not recommend routine testing when the patient has no change in clinical status or when a physician is unlikely to change care for the patient based on the results of testing. A common example of overuse of echocardiography when not indicated is the use of routine testing in response to a patient diagnosis of mild
valvular heart disease Valvular heart disease is any cardiovascular disease Cardiovascular disease (CVD) is a class of diseases that involve the heart The heart is a muscle, muscular Organ (anatomy), organ in most animals, which pumps blood through the blood ...
. In this case, patients are often asymptomatic for years before the onset of deterioration and the results of the echocardiogram would not result in a change in care without other change in clinical status. Echocardiography now has a vast role in
pediatrics Paediatrics ( also spelled pediatrics or pædiatrics) is the branch of medicine Medicine is the science Science () is a systematic enterprise that builds and organizes knowledge Knowledge is a familiarity, awareness, or understan ...

pediatrics
, diagnosing patients with valvular heart disease and other congenital abnormalities. An emerging branch is
fetal echocardiography Fetal echocardiography, or Fetal echocardiogram, is the name of the test used to diagnose cardiac conditions in the fetal stage. Cardiac defects are amongst the most common birth defects. Their diagnosis is important in the fetal stage as it might ...
, which involves echocardiography of an unborn fetus.


Types

There are three primary types of echocardiography: transthoracic, transesophageal, and intracardic. Stress testing utilizes tranthoracic echo in combination with an exercise modality (eg, a treadmill). Intravascular ultrasound is included below, but is as the name indicates more "ultrasound" than "echocardiography" as it is imaging the walls of a vessel rather than the heart.


Transthoracic echocardiogram

A standard echocardiogram is also known as a transthoracic echocardiogram or cardiac ultrasound. In this case, the echocardiography transducer (or probe) is placed on the chest wall (or
thorax The thorax or chest is a part of the anatomy Anatomy (Greek ''anatomē'', 'dissection') is the branch of biology Biology is the natural science that studies life and living organisms, including their anatomy, physical structure, Bioc ...
) of the subject, and images are taken through the chest wall. This is a non-invasive, highly accurate, and quick assessment of the overall health of the heart.


Transesophageal echocardiogram

This is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's
esophagus The esophagus (American English American English (AmE, AE, AmEng, USEng, en-US), sometimes called United States English or U.S. English, is the set of varieties of the English language native to the United States. Currently, American E ...

esophagus
. This allows image and Doppler evaluation from a location directly behind the heart. This is known as a transesophageal echocardiogram. Transesophageal echocardiograms are most often used when transthoracic images are suboptimal and when a more clear and precise image is needed for assessment. This test is performed in the presence of a cardiologist, registered nurse, and ultrasound technologist. Conscious sedation and/or localized numbing medication may be used to make the patient more comfortable during the procedure.


Stress echocardiography

A stress echocardiogram, also known as a stress echo, uses ultrasound imaging of the heart to assess the wall motion in response to physical stress. First, images of the heart are taken "at rest" to acquire a baseline of the patient's wall motion at a resting heart rate. The patient then walks on a treadmill or uses another exercise modality to increase the heart rate to his or her target heart rate, or 85% of the age-predicted maximum heart rate (220 − patient's age). Finally, images of the heart are taken "at stress" to assess wall motion at the peak heart rate. A stress echo assesses wall motion of the heart; it does not, however, create an image of the coronary arteries directly. Ischemia of one or more coronary arteries could cause a wall motion abnormality, which could indicate coronary artery disease. The gold standard test to directly create an image of the coronary arteries and directly assess for stenosis or occlusion is a cardiac catheterization. A stress echo is not invasive and is performed in the presence of a licensed medical professional, such as a cardiologist, and a cardiac sonographer.


Intracardiac echocardiography

Intracardiac echocardiography (ICE) is specialized form of echocardiography that uses catheters to insert the ultrasound probe inside the heart to view 2D structures from within. ICE is often used as a part of cardiac procedures such as crossing the
interatrial septum The interatrial septum is the wall of tissue that separates the right and left atria of the heart The heart is a muscle, muscular Organ (anatomy), organ in most animals, which pumps blood through the blood vessels of the circulatory system. ...
with a transseptal puncture to permit catheter access from the right atrium to the left atrium. ICE has the benefit over transthoracic echocardiography in that an operator who is performing a sterile procedure can also operate the ICE catheter and ICE is not limited to visibility problems that can arise with transthoracic echo. Semi-invasive transesophageal echo has fewer visibility difficulties as transthoracic, but requires a second non-sterile operator to perform. ICE is often inserted through the femoral vein and into the right atrium. From the right atrium, visualization of the interatrial septum, all four cardiac chambers, all four valves, and the pericardial space (for an effusion) can be readily visualized.


Intravascular ultrasound

Intravascular ultrasound (IVUS) is a specialized form of echocardiography that uses a catheter to insert the ultrasound probe inside blood vessels. This is commonly used to measure the size of blood vessels and to measure the internal diameter of the blood vessel. For example, this can be used in a
coronary angiogram A coronary catheterization is a minimally invasive procedure to access the coronary circulation and blood filled chambers of the heart using a catheter. It is performed for both diagnostic and interventional (treatment) purposes. Coronary cathet ...
to assess the narrowing of the coronary artery. If the catheter is retraced in a controlled manner, then an internal map can be generated to see the contour of the vessel and its branches.


Modes

The various modes listed below essentially describes how the ultrasound crystals are used to obtain information. These modes are common to all types of echocardiography.


A-mode

Amplitude mode is not a mode used in modern echocardiography.


B-mode / 2D

Brightness mode is often synonymous with "2-D" and is very commonly used in echocardiography.


M-mode

Motion mode is infrequently used in modern echocardiography. It has specific uses and has the benefit of very high temporal fidelity (eg, measuring LV size at end diastole).


Strain rate imaging (deformation echocardiography)

Strain rate imaging is an ultrasound method for imaging regional differences in contraction (dyssynergy) in for instance
ischemic heart disease Coronary artery disease (CAD), also called coronary heart disease (CHD), Ischemia, ischemic heart disease (IHD), or simply heart disease, involves the reduction of blood flow to the myocardium, heart muscle due to build-up of plaque (atherosclero ...
or dyssynchrony due to
Bundle branch block A bundle branch block is a defect of the bundle branches or fascicles in the electrical conduction system of the heart The electrical conduction system of the heart transmits signals generated usually by the sinoatrial node to cause contraction ...

Bundle branch block
. Strain rate imaging measures either regional systolic deformation (strain) or the rate of regional deformation (strain rate). The methods used are either tissue Doppler or Speckle tracking echocardiography.


Three-dimensional echocardiography

Three-dimensional echocardiography (also known as
four-dimensional A four-dimensional space (4D) is a mathematical extension of the concept of three-dimensional or 3D space. Three-dimensional space Three-dimensional space (also: 3-space or, rarely, tri-dimensional space) is a geometric setting in which thr ...
echocardiography when the picture is moving) is now possible, using a matrix array ultrasound probe and an appropriate processing system. This enables detailed anatomical assessment of cardiac pathology, particularly valvular defects, and cardiomyopathies. The ability to slice the virtual heart in infinite planes in an anatomically appropriate manner and to reconstruct three-dimensional images of anatomic structures make it unique for the understanding of the congenitally malformed heart. Real-time three-dimensional echocardiography can be used to guide the location of bioptomes during right ventricular endomyocardial biopsies, placement of catheter-delivered valvular devices, and in many other intraoperative assessments. Three-dimensional echocardiography technology may feature anatomical intelligence, or the use of organ-modeling technology, to automatically identify anatomy based on generic models. All generic models refer to a dataset of anatomical information that uniquely adapts to variability in patient anatomy to perform specific tasks. Built on feature recognition and segmentation algorithms, this technology can provide patient-specific three-dimensional modeling of the heart and other aspects of the anatomy, including the brain, lungs, liver, kidneys, rib cage, and vertebral column.


Contrast echocardiography

Contrast echocardiography or contrast-enhanced ultrasound is the addition of an ultrasound contrast medium, or imaging agent, to traditional ultrasonography. The ultrasound contrast is made up of tiny microbubbles filled with a gas core and protein shell. This allows the microbubbles to circulate through the cardiovascular system and return the ultrasound waves, creating a highly reflective image. There are multiple applications in which contrast-enhanced ultrasound can be useful. The most commonly used application is in the enhancement of LV endocardial borders for assessment of global and regional systolic function. Contrast may also be used to enhance visualization of wall thickening during stress echocardiography, for the assessment of LV thrombus, or for the assessment of other masses in the heart. Contrast echocardiography has also been used to assess blood perfusion throughout myocardium in the case of coronary artery disease.


Accreditation

Echocardiography can at many times be subjective, meaning that the person performing the echo may have personal input that affects the interpretation of the findings. This leads to so-called "inter-observer variability", where different echocardiographers might produce different reports when examining the same images. This necessitated the development of accreditation programs all around the world. The aim of such programs is to standardize the practice of echocardiography and to ensure that practitioners have the proper training prior to practicing echocardiography which will eventually limit inter-observer variability.


Europe

At the European level individual and laboratory accreditation is provided by the European Association of Echocardiography (EAE). There are three subspecialties for individual accreditation: Adult Transthoracic Echocardiography (TTE), Adult Transesophageal Echocardiography (TEE) and Congenital Heart Disease Echocardiography (CHD).


UK

In the UK, accreditation is regulated by the British Society of Echocardiography. Accredited radiographers, sonographers, or other professionals are required to pass a mandatory exam.


United States

The "Intersocietal Accreditation Commission for Echocardiography” (IAC) sets standards for echo labs across the US. Cardiologists and sonographers who wish to have their laboratory accredited by IAC must comply with these standards. The purpose of accreditation is to maintain quality and consistency across echocardiography labs in the United States. Accreditation is offered in adult and pediatric transthoracic and transesophageal echocardiography, as well as adult stress and fetal echo. Accreditation is a two-part process; first, each facility will conduct a detailed self-evaluation, paying close attention to the IAC Standards and Guidelines. The facility will then complete the application and submit actual case studies to the board of directors for review. Once all requirements have been met, the lab will receive IAC certification. IAC certification is a continual process and must be maintained by the facility, this may include audits or site visits by the IAC. There are several states in which Medicare and/or private insurance carriers are requiring either the accreditation of the laboratory and/or sonographer credentialing for reimbursement of echocardiograms. There are two credentialing bodies in the United States for sonographers, the ''Cardiovascular Credentialing International'' (CCI), established in 1968, and the ''American Registry for Diagnostic Medical Sonography'' (ARDMS), established in 1975. Both CCI and ARDMS have earned the prestigious ''ANSI-ISO 17024'' accreditation for certifying bodies from the International Organization for Standardization (''ISO''). Accreditation is granted through the American National Standards Institute (ANSI). Recognition of ARDMS programs in providing credentials has also earned the ARDMS accreditation with the National Commission for Certifying Agencies (NCCA). The NCCA is the accrediting arm of the National Organization for Competency Assurance (NOCA). Under both credentialing bodies, sonographers must first document completion of prerequisite requirements, which contain both didactic and hands-on experience in the field of ultrasound. Applicants must then take a comprehensive exam demonstrating knowledge in both the physics of ultrasound and the clinical competency related to their specialty. Credentialed sonographers are then required to maintain competency in their field by obtaining a certain number of Continuing Medical Education credits, or CME's. In 2009, New Mexico and Oregon became the first two states to require licensure of sonographers. The American Society of Echocardiography (ASE) is a professional organization made up of physicians, sonographers, nurses, and scientists involved in the field of echocardiography. One of the most important roles that the ASE plays is providing their recommendations through the ASE Guidelines and Standards, providing resource and educational opportunities for sonographers and physicians in the field. There have been various institutes who are working on use of
Artificial intelligence Artificial intelligence (AI) is intelligence Intelligence has been defined in many ways: the capacity for abstraction Abstraction in its main sense is a conceptual process where general rules and concept Concepts are defined as abstra ...

Artificial intelligence
in Echo but they are at a very early stage and still needs full development.


Terminology

The most commonly used terminology for echocardiography diagnostic parameters are: * BSA –
body surface areaIn physiology Physiology (; ) is the scientific study of functions and mechanisms in a living system. As a sub-discipline of biology Biology is the natural science that studies life and living organisms, including their anatomy, physical ...
* DT – deceleration time * IVRT – isovolumic relaxation time * LA – left atrium * RA – right atrium * LV – left ventricle * RV – right ventricle * LVOT – left ventricular outflow tract * PHT – pressure half time * TAPSE – tricuspid annular plane systolic excursion * VC – vena contracta * EDD – end diastolic diameter * ESD – end systolic diameter * IVSd – interventricular septal end diastole * PWd – posterior wall thickness * LVMI – left ventricular mass index * Ao asc –
ascending aorta The ascending aorta (AAo) is a portion of the aorta The aorta ( ) is the main and largest artery An artery (plural arteries) () is a blood vessel The blood vessels are the components of the circulatory system The circulator ...

ascending aorta
* ST Jxn - sinotubular junction * LAVI - left atrial volume index * EDV - end-diastolic volume * ESV - end-systolic volume * EF -
ejection fraction An ejection fraction (EF) is the volumetric fraction A fraction (from Latin ', "broken") represents a part of a whole or, more generally, any number of equal parts. When spoken in everyday English, a fraction describes how many parts of a certa ...
* FS -
fractional shortening A ventricle is one of two large chambers toward the bottom of the heart that collect and expel blood received from an atrium (heart), atrium towards the peripheral beds within the body and lungs. The atrium (an adjacent/upper heart chamber that is ...
* RAVI - right atrial volume index * RVOT - right ventricular outflow tract * RVD - basal RV diameter * IVC -
inferior vena cava The inferior vena cava is a large vein that carries the deoxygenated blood Blood is a body fluid Body fluids, bodily fluids, or biofluids are liquid A liquid is a nearly incompressible In fluid mechanics or more generally conti ...

inferior vena cava
* GLS – global longitudinal strain * RVSP – right ventricular systolic pressure


See also

*
Angiogram Angiography or arteriography is a medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs o ...

Angiogram
* Aortic valve area calculation *
Electrocardiogram Electrocardiography is the process of producing an electrocardiogram (ECG or EKG). It is a graph of voltage Voltage, electric potential difference, electromotive force emf, electric pressure or electric tension is the difference in elec ...

Electrocardiogram
*
Fetal echocardiography Fetal echocardiography, or Fetal echocardiogram, is the name of the test used to diagnose cardiac conditions in the fetal stage. Cardiac defects are amongst the most common birth defects. Their diagnosis is important in the fetal stage as it might ...


References


External links


Echocardiography (Views, normal values, measurements, free software...) - TECHmED

VIRTUAL TEE – online self-study and teaching resource

VIRTUAL Transthoracic Echocardiography - online self-study and teaching resource

echocardia - online self-study and teaching resource

Echobasics – free online echocardiography tutorial

CT2TEE – transesophageal echocardiography simulator
{{Authority control Cardiac imaging Medical ultrasonography Radiology Cardiology