Mohd Farid

Mohd Farid

Saturday, September 29, 2012

The Sonographer Attachment Programme At USA Report : Mayo Clinic: Sonographer Experience =LV And RV Strain=



Imaging For (Speckle) Strain With Intent To Analyze In Room




-Don’t change data flow, leave in internal hard drive/dicom server.

-Turn off dual focus – move focus from bottom of screen to middle of screen.

-Check depth and width for each of the three apical windows (Apical Long Axis, Apical 4 Ch, Apical 2 Ch) for LV before start acquiring.

-All three views from each view have to have identical depth/width/frame rate.

-Frame rate has to be >40 fps, if not turn frame rate knob one click clockwise.

-Do the best you can in the room to acquire clips with very similar heart rates.

-Watch to see if rate changes with held breath in or out.

-If Atrial Fibrillation/Irregular HR, increase clip storage from 3 beats to 5 beats or more.

-If irregular HR, look for similar R-R interval for each apical view and isolate cardiac cycle with number of cycles knb. Change to one cycle, then with cycle select knob pick which cardiac cycle you want work with before assigning view label (Apical Long Axis, Apical 4 Ch, Apical 2 Ch).

-Analyze Apical Long Axis first. If not tracking correctly, push the “Recale” butto. Next view is about do we want to analyze only to aortic valve closure or later. Don’t change a thing, just click on kidney button.

-Before moving on to next view, click on quad view button. Make sure mark on waveforms is where it should be. If mark is on the early systolic upward part of waveform, move to downward part of waveform in late systole by clicking on mark. The waveform turns a bold color, then move to desired location (machine will not allow to move past valve valve closure), also in this view:note numbered results on 2D image-clip image.

-Do same for Apical 4 Ch then Apical 2 Ch view.

-May see message about aortic valve closure problems. If so, you will not get a bull’s eye composite view, but with 3 clipped quad views you will have all strain numbers except the apical cap.

Speckle Strain Is Done

-Measure LVOT for event timing.

-Acquire narrowed sector view of inferoseptum with TDI on, then analyze Doppler based strain of basal segment.

-No need to acquire the three full TDI views for backup; speckle strain is already done
-Continue on with the normal echo exam

If Images Are Difficult Or Having Wall Tracking Problems

-End your exam by clicking on New Patient; change data flow to interal hard drive.

-Pick study you were working on, click on select, not create, continue-No.

-Acquire strain study to be sent out to GE echo pac. All images, including the three apical views, full TDI and LVOT Doppler.

-Send out to echo pac, change data flow back to internal hard drive dicom/server.

-Pick study you were working on, click on select, not create, continue-No.

-Finish regular echo examination.

Heart Rate And Strain Waveform Issue On GE Echo Pac

-If irregular HR, look for similar R-R interval for each apical view, isolate with number of cycles arrows, and change to one cardiac cycle. Then with cycle select arrows, pick which cardiac cycle you want to work with before assigning label (ALAX,4Ch, 2 Ch).

-Still having HR problems?

-Click on quad view (after successfully analyzing each individual view) to get the strain info.
.
-You will see the strain results for each wall from that view.

-Do the same for each view.

-You will not get a composite bull’s eye view.

-You will not get strain of the apical cap.

Strain (Speckle) Final Check

-Check to see if strain waveforms make sense in the 3 strain waveform and bull’s eye view.

-Make sure mark on waveform is where it should be. If mark is on the early systolic upward part of waveform, move to most downward part of waveform in late systole by clicking on mark. The waveform will turn a bold color, then move to desired location (machine will not allow to move past valve closure).

-For cases where more than 2 segments cannot be visualized, it also cannot be evaluated by 2D speckle strain, Doppler strain should be used.

Strain Updates

-Make sure QRS complex is highest upward deflection not P or T waves.

-Measure strain only until aortic valve closure for Doppler and speckle are determined.

-Wall segments that are not tracking by speckle strain need to be analyzed by Doppler stra

-Frame rate needs to be above 200 fps for Doppler based strain, narrow sector.

-When analyzing Doppler strain make sure strain start bracket is at start of QRS complex, not start of P wave.

-General strain news : with the Vivid E9 Echo Machine we cannot manipulate the waveforms until all three views are completed and you are at the bullseye with three quad views. With Doppler based strain on Vivid E9 click on the strain button before you click on the Q analysis button. Enter strain numbers into your system if necessary from bull’s eye not from the stored quad views, the results will be different if entered from quad view rather from Bullseye. After analyzing the 2 Chamber View remember to store the 2 Chamber Quad View, the Vivid E9 bypasses this step.

LV Strain Acquisition And Analysis

-Turn off dual focus-move focus from bottom of screen to middle of screen.

-Check depth and width for each of the three apical windows for LV before you start acquiring-all three views from each view have to have identical depth/width/frame rate.

-Frame rate has to be > 40 fps-if not turn frame rate knob one click clockwise.

-Do the best you can in the room to acquire clips with very similar heart rates.

-Watch to see if rates changes with held breath in or out.

-If Atrial Fibrillation or Irregular Rhythm, increase clip from 3 beats to 5 beats or more.

-If irregular HR, look for similar R-R interval for each apical views and isolate cardiac cycle with number of cycles knob. Change to one cycle, then with cycle select knob pick which cardiac cycle you want with before assigning view label (Apical Long Axis, Apical 4 Ch, Apical 2 Ch).

-Analyze Apical Long Axis View first. If not tracking correctly, push the Recalc button (up by screen). Next view is about do we want to analyze only to aortic valve closure or later. Don’t change a thing, just click on kidney button.

-Before moving on to next view, click on quad view button. Make sure mark on waveform is where it should be. If mark is on the early systolic upward part of waveform-move to downward part of waveform in late systole by clicking on mark. The waveform turns a bold color, then move a desired location (machine will not allow to move past valve closure).

-Also in this view: note numbered results on 2D image-clip, save quad view.

-Do same for Apical 4 Ch and Apical 2 Ch Views.

-Measure LVOT for event timing, Aortic valve opening and Aortic valve opening.

-Acquire narrowed sector view of inferoseptum with TDI on, then analyze Doppler based strain of basal segment and save.

RV Strain

Goal

-Quantification of right sided longitudinal contractility in pulmonary hypertension patients.

-Patients undergoing an initial or subsequent PHTN echo will have longitudinal systolic strain recorded from the free wall of the right ventricle.

-Unlike the LV, the predominant orientation of muscle fibers in the RV is in the longitudinal plane.

-Measures of transverse/radial function do not directly reflect the major component of RV systolic function.

RV Strain Updates

With the new Vivid E9 just bring the RV center, analyze by calling it the Apical Long Axis View. That should be the only view needed. Pay close attention, the waveforms for the RV free wall will now be different than they would be when we analyzed by calling the RV the 4 Ch view.

General strain news: with the Vivid E9 we cannot manipulate the waveforms until all three views are completed and you are at the bullseye with three quad views. With Doppler based strain click on the strain button before you click on the Q analysis button.

RV Strain Image Acquisition

We don’t need Apical Long Axis View with the Vivid 7, machine will estimate aortic valve closure (sensing change in volumes), go directly to 4 Ch view

-Turn off dual focus-move single focus to approximately mid screen or to where image is most optimized.

-Narrow image sector and use tilt function (if needed) to isolate the RV.
-Frame rate has to be > 40 fps.

-Best results may come from a more lateral apical window
.
-Walls don’t need to be parallel to ultrasound beam due to nature of speckle analysis.

-Make sure depth is set appropriately so as not to cut off the lateral annulus.

-Insert point at base septum, base lateral wall, and apex.

-Place base septum and base lateral wall points at annulus.

-Pull points down to annulus, not beyond annulus.

-Place septal point at tricuspid insert side, not mitral insert side.

-Make sure apical point is at true apex.

-Should track the blood tissue interface, may need to move/increase ROI width to track.

-Will try our best to analyze with speckle strain.

-Problem wall will most likely be basal lateral wall.

-Septum does not need to track, not reporting septum.

-If unsuccessful, will acquire with Doppler strain.

To Analyze The RV Free Wall Doppler Based Strain

·         Before Doppler strain, do event timing using RVOT, instead of LVOT.
·         Measurements→Event Timing→Ao Valve Opening-Ao Valve Closing
·         Wall does need to be parallel with ultrasound beam
·         Frame rate needs to be > 200 fps

RV Strain Data

-RV Basal Lateral Peak %

-RV Mid Lateral Peak %

-RV Apical Lateral Peak %

-RV Lateral wall averaged peak systolic strain %

-Best to go to graphics pull down menu to strain (longitudinal systolic), as measurement page may be going away.

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