The Sonographer Attachment Programme At USA Report : Mayo Clinic: Sonographer Experience =Stress Echocardiogram=

Stress Echocardiography : Pre Test Limited Echo

·    Aorta Diameter

·    Left Ventricle Size

·    Left Ventricle Systolic Function

·    Left Ventricle Diastolic Function

·    Left Atrial Chamber Size

·    Right Ventricle Function

·    Tricuspid Regurgitation Peak Velocity

·    Aortic Valve (Assess AS/AR)

·    Mitral Valve (Assess MS/MR)

·    Preview (PLAX, PSAX-Papillary Muscle Level, Apical 4 Ch, Apical 2 Ch)

·    Preview If Poor PLAX (Apical 3 Ch, Apical 4 Ch, Apical 2 Ch, Apical SAX)

Dobutamine Stress Echo : Low Gradient Aortic Stenosis

>> Indication

·    For assessment of patient with LV dysfunction (EF < 45%) and mean transvalvular gradient < 40 mmHg.

>> Protocol

Graded dobutamine infusion using usual doses, until LV TVI is maximized (usually ± 20 mcg/kg/min)

Obtain measurements at rest, repeat, at each stage of dobutamine infusion (starting at 2.5 mins of the stage), complete before each increment in dose

>> Measurement

LVOT diameter (rest only)

LVOT velocity and TVI (each stage)

AV velocity TVI, and mean gradient (each stage) using the window which provides maximum velocity at rest

>> Calculations

·    Determine AV Area

·    Using the continuity equation and both peak velocity and TVI methods

·    Calculate at baseline and at each stage of dobutamine infusion

Low Flow Low Gradient Aortic Stenosis
Dose (mcg/kg/min)	Duration (minutes)
5	5
10	5
15	5
20	5

Echo Measurement
Baseline (Rest)	10 mcg/kg/min	20 mcg/kg/min
LVOT Diameter	-	-
LVOT Vmax	LVOT Vmax	LVOT Vmax
AV Vmax	AV Vmax	AV Vmax
AV Mean Gradient	AV Mean Gradient	AV Mean Gradient

Supine Bicycle Stress Test For Patients With HOCM

·    Exercise Test (Supine Bicycle Exercise)

·    minutes every stage

·    Start 25 watts and increase by 25 watts every stage

·    2D echo acquired - Standard wall motion assessment at rest and peak stress

·    Doppler data acquired

-          TR velocity at rest and each stages of stress

-          MV Inflow data including E velocity at rest and at each stage of stress

-          Doppler TDI (mitral annulus,septum) at rest with measurement of E’

-          CW of LVOT at rest and each stage

Characteristic Of Chest Pain

·    Typical Angina (must have all 3 characteristic)

-          Substernal Location

-          Provocation By Exercise

-          Relief By Rest Or NTG Within 10 Minutes

·    Atypical Angina (must have any two of the above)

·    Non Anginal Chest Pain (one of the symptom present)

·    Asymtomatic

Image Acquisition For 3D Volumes (IE 33 Philips)

>> Select Transducer

·    Select “Preset/Tranducer” on left touch screen.

·    Select “X3-I” on left touch screen.

·    Select “3D Modalities” on left touch screen.

>> Optimize ECG

·    Very important to have best ECG tracing possible, image acquisition is gated to ECG.

·    Change ECG to lead I, lead II and lead III to see which give best signal (physio button).

·    Increase ECG gain and try to have an upward deflection of the QRS if possible.

>> Obtain Image

·    Apical 4 Chamber LV on the right side of screen (index marker 3 o’clock).

·    Adjust depth to include all of LV and part of LA (center the LV on the screen).

>> Optimize Gain

Center all TGCs and LGCs, press iSCAN.

Select “Live 3D” on right touch screen.

Use TGCs and LGCs to optimize gain (try to make gain as consistent as possible throughout entire LV).

Gain in apex usually need to be turned down.

Gain in LV usually need to be turned up.

Undergaining will cut out structures.

It is better to slightly overgain to assure all information is acquired, but too much gain will “fog” or “mask” out structures (fogging is often seen in apex).

>> Obtain Full Volume

Select “Full Volume” on right touch screen.

Select “Low, Medium, Or High Density” (Low Density works well for LV Volumes).

Higher Density gives better resolution, but decreases sector size and increases number of cycles needed to obtain full volume (useful for detailed structure).

Low density gives lower resolution, but allows bigger sector size (Dilated LV) and less cardiac cycles for acquisition (less time for breath holding).

Select From Full Volume Option (three settings).

Volume Size give the largest sector size (monster volume on low density setting).

Acq Beats (resolution is better than using volume size setting, use for volumes if apex fits in sector).

Frame Rate (will give you better frame rate by giving more beats during acquisition.

Entire LV must fit within the blue lines on both images on the screen.

Have patient hold breath and press acquire (the next 4-7 beats wil be acquired).

While acquiring patient and transduser can not move or there will be artifact.

>> Check For Artifact

·    Check ECG for ectopics.

·    Check image for artifact.

Image will be displayed in auto crop, select “Reset Crop” on right touch screen (image will now be shown as the full volume pyramid).

Roll track ball down so you are looking at the top of the pyramid, check for holes.

Select “Crop Adjust Box” (bottom left of the right touch screen).

Select “Blue Min” plane and crop down in to the LV, check for stitch artifact.

·    If image is good select “Accept Full Volume” on left touch screen.

·    If image is not good select “Reject Full Volume” on left touch screen.