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ISBN: 9780470659977 A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. However, there will be also times when you will need to access quick reference information to help you manage a crashing patient in an urgent situation. This reference guide will provide you everything you need to establish a differential and accurate diagnosis that will lead you to best manage a cardiovascular patient in an emergent situation. With the first part devoted to basic instrumentation and image acquisition and the second part focusing on the different clinical situations that often require evaluation by echocardiography in the urgent setting, this book is the ideal companion to the physician who needs to implement rapid life and death decisions. It is designed to help in situations where seconds and minutes can really make a difference in the lives of patients. Even one extra saved life will justify the large amount of work that the authors have put into this work. Vladimir Fridman and Mario Garcia CHAPTER 1 Ultrasound physics Vladimir Fridman Cardiovascular Diseases, New York, NY, USA Echocardiography is one of the most valuable diagnostic tests for the evaluation of patients with suspected cardiovascular disease in the acute setting. Even though echocardiography has become more widely available, its performance and interpretation require practice and knowledge of the principles of image formation. Although the physical principles and instrumentation of ultrasound can be quiet complex, there are a few basic concepts that every echocardiographer and interpreting physician must understand to maximize the diagnostic utility of this test and avoid misinterpretations. These key concepts are covered in this chapter. Although slight changes in control positions are noted between machines from different companies, all machines have the key controls that are shown in these images. The panel from above image, is split into three frames, and the important controls are labeled below. Figure 1.1 Echocardiogram machine. Figure 1.2 Typical echocardiogram control panel. Figure 1.3 Echocardiography settings. The important echocardiographic settings as displayed on the monitor of most ultrasound machines are shown in Figure 1.3. These settings can be changed, as needed, to adjust the image quality. Ultrasound generation Ultrasound is a cyclic sound pressure waveform whose frequency is greater than the limit of human hearing. This number is generally considered to be 20 kHz, or 20 000 Hz (Hertz). Echocardiography usually relies on sound waves ranging from 2 to 8 MHz. The echocardiograph, or any other medical ultrasound machine, produces these high frequency sound waves using transducers that contain a piezoelectric crystal. A piezoelectric crystal (such as quartz or titanate cyramics) is a special material that compresses and expands as electricity is applied to it. This compression and expansion generates the ultrasound wave. The rate (frequency) of compression and expansion is based on the current that the ultrasound machine applies to the piezoelectric signal, which in turn is based on the settings the operator has selected on the machine. In an echocardiogram machine, current is applied to the piezoelectric crystal, which then emits ultrasound energy into human tissue. The ultrasound is emitted in pulses that usually consist of several consecutive cycles of a sound wave with the same frequency separated by a pause (Figure 1.10). An extremely important concept for ultrasound is the frequency of pulses that the ultrasound emits; this is called the Pulse Repetition Frequency (PRF). Once an ultrasound pulse is emitted from the transducer, the entire mechanism enters the “listening” phase. At this time, the ultrasound machine is waiting to receive back the pulse it emitted after it was reflected from distant structures. It is important to know that the ultrasound machine spends almost 99 of the time listening for, and 1 of the time generating, a signal. Image formation As the ultrasound wave exits the echocardiogram probe, it enters the human tissue. Thus, ultrasound energy is greater near the transducer and is progressively lost as it penetrates into the tissue. The ultrasound systems typically compensate by amplifying more the signals that are received from the far field to make the image homogeneous. The interaction of ultrasound with human tissue is also very complex. However, it is not always the truth. The velocities of ultrasound in various human tissues are shown in Table 1.1. This concept is extremely important, since the ultrasound machine is not able to recognize whether the ultrasound it receives back from the body traveled mainly through bone, through soft tissue, through air, or any combination of the above structures. This explains why interposition of ribs or lung tissue between the transducer and the heart will produce severe imaging artifacts and make part of the image uninterpretable (Figure 1.11). Table 1.1 Velocity of ultrasound in various human tissues. As clearly seen, the quality of the myocardial image declines acutely as more air enters the lung of the patient, to a point where no myocardium is seen in full inhalation (c). Another important point to remember is the behavior of the ultrasound beam as it emerges from the transducer (Figure 1.12). The ultrasound beam is initially parallel and cylindrical (near zone). However, after its narrowest point, the focal zone, it begins to diverge and acquires a cone shape (far zone). For reasons outside the scope of this book, the imaging is much better if the object of interest is located near the focal zone. Ultrasound Physics and Instrumentation. Resolution versus penetration The behavior of the beam within tissue determines the lateral resolution of the ultrasound, or the ability to distinguish two objects located side by side on an ultrasound image. At higher frequency, axial resolution increases. However, since the ultrasound signal is attenuated as it travels through the tissues, more attenuation occurs. In general, high frequency is preferred for imaging structures that are closer to the transducer and lower frequency for those that are far. In the case shown in Figure 1.13, a parasternal long axis view loses its definition as the transducer frequency is changed from 4.0 MHz to 2.0 MHz. As the ultrasound comes back to the transducer, the same piezoelectric properties of crystal that allow the ultrasound waves to be made allow the conversion of the received ultrasound waves into electrical signals. A typical 2D ultrasound transducer has 128 or 256 individual crystal-electronic interphases. By alternating the time and sequence in which these are stimulated, the ultrasound beam can be steered at almost any angle. The higher the number, the more accurate the image. The larger the angle, the more structures are visualized in the image, but the slower image acquisition takes place. The larger the depth, the longer it takes for the ultrasound to receive the reflected ultrasound waves from those structures, and the slower the image acquisition occurs. Doppler ultrasound Doppler images are generated based on a different set of physical principles. The frequency of an ultrasound wave changes slightly when reflected by an object that is either approaching (increasing), or moving away (decreasing), from the source of the wave (Figure 1.19a). This is applied in echocardiography to measure the velocity of a moving column of blood or the myocardium itself (tissue Doppler). When the reflected waves return back to the ultrasound probe, the change in frequency detected allows the echocardiograph to determine the velocity of the moving reflector. A major limitation of Doppler imaging is that, for it to be accurate, the reflector should be traveling in a parallel direction to the ultrasound wave. If the reflector travels at an angle, only the parallel component of the vector of motion is detected. In echocardiography, there are two major types of Doppler modes used: Continuous Wave (CW) Doppler and Pulsed Wave (PW) Doppler. Continuous Wave (CW) Doppler is the older and electronically simpler of the two types of Doppler. It involves continuous generation of ultrasound waves by the transducer and continuous reception of ultrasound waves by the transducer. It requires at least a two crystal transducer, with one crystal devoted to each of the functions. Because in CW Doppler ultrasound the ultrasound waves are sent continuously, more waves are sent in a given period of time and the receiver can detect larger shifts in frequency, thus providing a higher range of velocity resolution. At the same time, since there are no pauses between ultrasound pulses, the receiver cannot determine the pulse travel time, and thus cannot localize the depth of reflectors. If there are several objects moving at different velocities across the path of the ultrasound beam, the transducer will record multiple frequency shifts, producing a dense spectral image where only the maximum velocity can be identified. Pulsed Wave (PW) Doppler involves a transducer that alternates between sending and receiving the ultrasound waves. Because less ultrasound waves are sent in a given period of time the maximum frequency shift that can be detected is limited but the depth where the velocity shift occurs may be determined by measuring the travel time of the ultrasound pulses. Figure 1.20 Adjustment of sample volume prevents Doppler artifacts. Figure 1.21 Effect of changing the sweep speed on echocardiographic images. Aliasing is a phenomenon that occurs when the object being interrogated by PW Doppler is moving faster than the maximum velocity the PW can interrogate (Nyquist limit). The resulting image places portion of the Doppler image above the baseline, and a portion wraps around and starts below the baseline (Figure 1.24). This image is uninterpretable and CW should be used instead in this case. Figure 1.24 PW Doppler of the mitral flow. The mitral regurgitation jet is seen aliasing. Figure 1.25 Aliasing of the mitral inflow on the left-hand image is fixed by a lower baseline on the right-hand image. The mathematical principle behind aliasing is complex. However, it is important to know that it depends on the pulse repetition frequency (PRF), which is determined by the interval between pulses. For example, if the velocity of the flow of interest exceeds the Nyquist limit and the reflector is moving away from the transducer, the Nyquist limit may be increased by shifting the baseline (Figure 1.25). For a novice echocardiographer, it is always hard to determine whether to use PW or CW for interrogation of specific flows. As a quick rule, major stenotic and regurgitant lesions should be interrogated with CW, but flows that need to be interrogated at a specific location should be interrogated with PW. Figure 1.26 Effect of changing the Doppler gain on echocardiographic images. Another important Doppler modality is color Doppler. When color Doppler is used to interrogate an area on a two-dimensional image, the velocities of all flows in this area are displayed on a color map (usually, red represents movement toward the transducer and blue away from the transducer). The colors represent the velocities of flow at the point in which the color is displayed. This type of imaging is very frequently used to visualize regurgitant and turbulent flows within all the structures of the heart. The smaller the area, the more accurate the signal. As shown in Figure 1.26, a lot of artifacts are created when the color Doppler is overgained. Here, a moderate to severe MR signal is turned into an interpretable image when the color Doppler gain is increased fully. The golden rule is that color Doppler gain should be set to a setting just below the level at which speckles of color Doppler signal are seen in the background images (such as on the myocardium itself, where no flow is occurring). Set by pulse repetition frequency (PFR). Changing this setting will alter the range of velocities that are displayed on the color Doppler screen (Figure 1.27). Tissue Doppler uses the basic Doppler principles to record myocardial tissue velocities. It is very useful in evaluating myocardial systolic and diastolic function. It may be applied in pulsed or color modes. Figure 1.27 Effect of changing the color Doppler baseline on echocardiographic images. Summary and key points. No account? Create one! No account? Create one! No account? Create one! Please be the first to add one. Peri-Procedural Prevention and Treatment Utilizarea in continuare a site-ului implica acceptarea acestor politici, clauze ?i condi?ii. The Sponsored Listings displayed above are served automatically by a third party. Neither the service provider nor the domain owner maintain any relationship with the advertisers. 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