The Sonographer Attachment Programme At USA Report : Mayo Clinic: Sonographer Experience =Pulmonary Hypertension=

Pulmonary Hypertension : Initial Standard TTE Examination

>> Parasternal RV Outflow View

- 2D assessment with or without color Doppler of pulmonary valve

- CW Doppler for peak and end diastolic PR velocity

- PW Doppler of RVOT TVI

>> Apical Four Chamber View

- Focus on RV

- Bring the RV toward the center of the screen – minimize foreshortening

- Do not use a para apical view

- 2D assessment of RV size and systolic function

- RV end diastolic basal and mid ventricular dimensions and RV length

- Area and length measurements of RA

- M-Mode through lateral tricuspid annulus (TAPSE)

- Lateral tricuspid annulus TDI S’

- RV Strain

>> Subcostal View

- Inferior vena cava through one respiratory cycle and then sniff

- PW Doppler of hepatic vein flow or SVC flow

>> Arch View

- SVC flow

O2 saturation at rest

Pulmonary Hypertension : Follow Up

>> Parasternal Long Axis View

- 2D with and without Color Doppler of AV & MV

- LV dimensions and EF

- LVOT diameter

>> Parasternal RV Inflow View

- 2D with and without Color Doppler of TV

- Peak TR velocity

>> Parasternal RV Outflow View

- 2D assessment with and without Color Doppler of pulmonary valve

- CW Doppler for peak and end diastolic PR velocity

- PW Doppler of RVOT TVI

>> Parasternal Short Axis View (Basal Level)

- 2D with and without Color Doppler of pulmonary valve

- CW Doppler for peak and end diastolic PR velocity

- 2D assessment with and without color Doppler of TV

- CW Doppler for peak TR velocity

- PW Doppler of RVOT TVI

>> Parasternal Short Axis View (Papillary Muscle & Apical Levels)

- 2D visual assessment of biventricular size and systolic function

>> Apical 4 Ch View

- Focus on RV

- RV size, systolic fx (2D)

- RV end diastolic base and mid dimensions and RV length

- RA volume index

- Color Doppler of TV

- Lateral tricuspid annulus TDI

- TAPSE

- RV Strain

>> Apical 4 Ch View

- Focus on LV

- 2D assessment of LV size and systolic function

- Mitral inflow velocity at leaflet tips

- Tissue Doppler of medial and lateral mitral annulus velocity

- LV outflow tract velocity and TVI

>> Subcostal View

- Inferior Vena Cava through one respiratory cycle and then sniff

- PW Doppler of hepatic vein flow

>> SVC Flow

>> RIMP Measurement

>> Pulse oximetry and record of oxygen use

Echocardiogram

What is an Echocardiogram?

An echocardiogram is a test that uses ultrasound waves to examine the heart. Because it is a non-invasive test, it is a safe and painless way to help doctors diagnose a number of abnormalities of the heart.

Is the Echocardiogram Safe?

The echocardiogram is very safe. It is a non-invasive procedure using ultrasound waves. There are no known risks from the ultrasound waves.

The echocardiogram is also painless, although you may feel slight discomfort when the transducer is held firmly against the chest.

What Does It Show?

Doctors can see how well your heart functions during exertion by studying what happens during the exercise test.

• Size and shape of the heart. The images may be used to measure the size of the heart chambers and thickness of the heart muscle.
• Pumping efficiency of the heart. The images show the efficiency with which the heart pumps blood, as well as whether the heart is pumping at full strength or is weakened. The scans may also show whether the various parts of the heart pump equally.
• Valve abnormalities. An echocardiogram shows the shape and motion of the heart valves. It can reveal if a heart valve is narrowed or leaking and show how severe the problem is.
• Other uses. The test may also detect the presence of fluid around the heart; blood clots, or masses inside the heart; and abnormal holes between heart chambers.

Preparing For A Test

• Do not eat or drink 3 hours prior to the test. This will prevent the possibility of nausea, which may accompany vigorous exercise after eating. If you are diabetic and take medications for diabetes, get special instructions from your doctor.
• If you are currently taking any heart medications, check with your doctor. You may be asked to stop certain medications a day or two before the test. This can help get more accurate test results.
• Wear loose, comfortable clothing that is suitable for exercise. Men usually don't wear a shirt during the test, and women generally wear a bra and a lightweight blouse or a hospital gown. You should also wear comfortable walking shoes or sneakers.
• Several areas on your chest and shoulders will be cleansed with alcohol and an abrasive lotion, to prepare the skin for the electrodes. Men may need to have areas of their chest shaved, to ensure that the electrodes stay in place.

What Happens During the Test?

The echocardiogram can be performed in the doctor's office or at the hospital. No special preparation is necessary for this test. If you are scheduled for an exercise echocardiogram, however, you will be given special instructions.

You will be asked to remove clothing above the waist, and put on a hospital gown or a sheet to help keep you warm and comfortable. You will then lie on an examination table.

Electrodes (small sticky patches) and wires will be attached to your chest and shoulders to record your electrocardiogram (ECG or EKG). The ECG shows your heart's electrical activity during the test.

Next, you will lie on your back or on your left side. To improve the quality of the pictures, a colorless gel is applied to the area of the chest where the transducer will be placed.

A technician moves the transducer over the chest, to obtain different views of the heart. He or she may ask you to change positions. You may also be asked to breathe slowly or hold your breath, in order to get a better picture. A thorough examination usually takes from 20 minutes to an hour, depending on the number of views and whether the Doppler echo is used.

How Does An Echocardiogram Work?

An echocardiogram works very much like sonar. Ultrasound waves are transmitted into the chest and the reflection of these waves off the various parts of the heart is analyzed by sophisticated equipment.

A transducer, which is a small microphone-like device, is held against the chest. The transducer sends and receives the ultrasound waves. By moving the transducer to various positions on the chest, different structures of the heart may be analyzed.

A computer assembles the reflected ultrasound waves to create an image of the heart. These images appear on a television screen. The images may be recorded on videotape or printed on paper for review by the cardiologist.

An echocardiogram study typically involves three different techniques. The most basic technique, called M-mode echo, produces an image that appears as a tracing than an actual heart. The exact size of the heart chambers may be measured using the M-mode echo technique.

Two-dimensional (2-D) echo shows the actual shape and motion of the different heart structures. This advanced technique provides images that represent "slices" of the heart in motion.

Doppler echo is a third technique that portrays the flow of blood through the heart. The images representing the flow of blood through the heart may be displayed as a series of black-and-white tracings or as color images on the television screen.

During a Doppler echo procedure, you will hear some unusual sounds. These whooshing or pulsating sounds are computer-generated to provide the technologist with audio feedback. They are not the sounds of your heart.

The Benefits

A Major benefit of the echocardiogram is that it gives information about the heart's structures and blood flow without anything other than sound waves entering the body. The information gained from the echocardiogram allows your doctor make an accurate diagnosis and develop a treatment plan that is best for you. The major limitation is that it is often difficult to obtain good quality images from persons who have broad chests, are obese, or are suffering from chronic lung disease.

The Results

Typically, the doctor will review the images at a later time and prepare a report detailing his findings.

Heart Anatomy

Right Coronary Left Anterior Descending Left Circumflex Superior Vena Cava Inferior Vena Cava Aorta Pulmonary Artery Pulmonary Vein	Right Atrium Right Ventricle Left Atrium Left Ventricle Papillary Muscles Chordae Tendineae Tricuspid Valve Mitral Valve Pulmonary Valve Aortic Valve (Not pictured)

Coronary Arteries

Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue.

The blood leaving the left ventricle exits through the aorta, the body’s main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart.

The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart.

Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver.

When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack.

Superior Vena Cava

The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the head and upper body feed into the superior vena cava, which empties into the right atrium of the heart.

Inferior Vena Cava

The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the right atrium of the heart.

Aorta

The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body.

Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart.

Pulmonary Vein

The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart.

Right Atrium

The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle.

Right Ventricle

The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve prevents blood from backing into the right atrium and the opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs.

Left Atrium

The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle.

Left Ventricle

The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body.

Papillary Muscles

The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles opens these valves. When the papillary muscles relax, the valves close.

Chordae Tendineae

The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings."

Tricuspid Valve

The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery.

Mitral Valve

The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta.

Pulmonary Valve

The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart.

Aortic Valve

The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart.