Echocardiography - Wendy Blountwendyblount.com/sono-lufkin/Oncura-EchocardiographyManual.pdf ·...

Confidential Oncura Partners Diagnostics, LLC 2015

Echocardiography


Ninety percent of the routine echocardiogram is done from the right parasternal window. This window is

found just dorsal to the sternum, on the right side of the chest in the cranial to mid thoracic region. To easily

identify this window, place the animal in the right recumbent position on a cardiac table with cutouts and feel

for the heartbeat. The point of maximum intensity will be your parasternal window and you should clip this

region (from the point of the elbow to the sternum). By placing the animal right side down and imaging from

underneath the animal, the weight of the heart acts to increase the size of the cardiac window, maximizing

visualization of the heart. The apical window can be found with the animal in the left recumbent position and

feeling for the point of maximum intensity. Once you find the cardiac window (where you get the best

images and lungs are not in the way), the patient respirations will create movement and will cause air filled

lung to move between the chest wall and the heart, which can make it difficult to see parts of the heart at

times.

The routine echocardiogram is accomplished by obtaining standard views of the heart in both long axis and

short axis. It is important to remember that “long axis” is a long axis of the heart - not the dog/cat (as we do

with abdominal ultrasound). In most animals, the heart sits at about a 45 degree angle in the chest, so your

probe will need to be at about a 45 degree angle to see a nice long axis of the heart. Short axis images of the

heart are obtained by rotating the transducer 90 degrees.

Cardiac measurements will be a very important part to a complete echocardiogram. We recommend that you

take your measurements in a short axis view with M-mode when possible in canine patients and B mode in

feline patients. B mode can also be used for measurements if you cannot produce a clear M mode image.

Once these direct measurements have been made, the ultrasound machine can then make calculations such as

ejection fraction.

You will notice that we recommend certain transducer notch position throughout this module. For training

purposes we recommend scanning the same way each time to produce consistent images. NOTE: you can still

obtain the images if the notch is position 180 degrees from what we recommend. Just remember that your

image will be flipped (the apex will appear on the other side of the image).

The following pages include a break down of the cardiac windows and measurements needed to obtain a

complete echocardiogram.

INTRODUCTION TO ECHOCARDIOGRAPHY


In order to get the best images possible for the customer and the radiologist, preparing your patient

will be necessary.

1- Palpate the heart at the point of maximum intensity on the r ight and left side. The r ight

parasternal window is found just dorsal to the sternum, on the right side of the chest in the

cranial to mid thoracic region

2- Clip a rectangular region at the parasternal and apical windows from the point of elbow down to

the sternum

3- Make yourself and the pet comfortable. Panting and nervous pets make it difficult to

obtain a quality exam. The room should be darkened and quiet. Most patients can be scan without

sedation, but in some cases proper sedation may be required to obtain an effective cardiac examination

A. In Giant breed dogs, we can often obtain adequate echo images in a standing or sitting

position, if this is easier on the patient. In feline patients we can often obtain adequate

images while the sonographer holds the patient in his/her lap to create a more

comfortable, less stressful experience.

4- Have plenty of ultrasound gel available. Applying alcohol after clipping and before applying

ultrasound gel can be helpful.

5- Have plenty of hand towels available. You will need them to wipe your hands when

they are slick with gel and to wipe off the pet and transducer when you are done with the exam.

6- Have an additional staff member to assist with proper restraint.

7- You will need proper positioning tools

A. A cardiac table with cutouts should be used if available

8- Have proper clean up supplies for cleaning the transducer when finished. Nobody likes to sit down to

start an exam and have to deal with a dirty, crusty, hairy transducer!

PREPARATION FOR ECHOCARDIOGRAPHY EXAMS

Ao Aorta

AV Aortic Valve

IVS Intraventricular Septum

IAS Interatrial Septum

LA Left Atrium

LAA Left Atrial Appendage

LV Left Ventricle

LVOT Left Ventricular Outflow Tract

LVPW Left Ventricular Posterior wall

MV Mitral Valve

PM Papillary Muscle

PV Pulmonic Valve

PE Pericardial Effusion

RA Right Atrium

RV Right Ventricle

RVOT Right Ventricular Outflow Tract

RVW Right Ventricular Wall

TV Tricuspid Valve

Common Echocardiography Abbreviations


ONCURA PARTNERS ECHOCARDIOGRAPHY PROTOCOL

Right Parasternal Long Axis

4-Chamber view: Image

4-Chamber view: Video

Color Doppler LA/MV: Video

LV Outflow Tract: Image

LV Outflow Tract: Video

Color Doppler LVOT/AV: Video

Right Parasternal Short Axis

Papillary Muscles: Image (x3)

Papillary Muscles: Video

M-Mode Image of Papillary Muscles (x3)

Mitral Valve: Image

Mitral Valve: Video

M-Mode Image of MV

5 Chamber (AV): Image (x3)

5 Chamber (AV): Video

Color Doppler RVOT/PV: Video

Left Apical Long Axis





Color Doppler LA/MV: Video

Color Doppler RA/TV: Video

Color Doppler LVOT/AV: Video

Right Parasternal Short Axis Measurements

2D Image of AV

LA and Aortic Root

Canine Patients: M-mode

IVSd, LVDd, LVPWd

IVSs, LVDs, LVPWs

Feline Patients: 2D

IVSd, LVDd, LVPWd

IVSs, LVDs, LVPWs

NOTE: take 3 measurements of each

Please provide the additional information if available when filling out the worksheet

Blood Pressure

Chest X-Ray (especially if symptom includes coughing*)

BNP

Chem Panel

UA

Weight of animal


Right Parasternal Long Axis Images

Patient Position

1. Place the animal in a right lateral recumbent position.

2. The animal should be placed on a cardiac table with cutouts.

3. NOTE: Some giant breed dogs can be scanned in a standing or sitting position to obtain an adequate

echo image. In feline patients we can often obtain adequate images while the sonographer holds the

patient in his/her lab to create a more comfortable, less stressful experience. FOR TRAINING

ONCURA RECOMMENDS USING A CARDIAC TABLE

Parasternal 4 Chamber View

1. Transducer position

A. The notch will be placed approximately at 7 o'clock (12 o’clock being the patients head)

2. Visible structures

A. You should see the LA, LV,

and MV clearly along with

a portion of the RA, RV, and

TV.

3. Required Images

A. Static image

B. Video clip

C. Color Doppler Video of MV/LA


Right Parasternal Long Axis Images

Parasternal 5 Chamber View

1. Transducer position

A. From the 4 chamber view you will SLIGHTLY TILT the beam cranially and clockwise

B. NOTE: This will be a very small change in transducer position

2. Visible structures

A. You should see the LV,

LVOT, AV and Aorta

root clearly

3. Required Images

A. Static Image

B. Video clip

C. Color Doppler Video of

AV/LVOT


Short Axis at Level of LV

1. Transducer Position

A. From a 4 chamber long axis view, SLOWLY ROTATE the transducer 90 degrees so that you

see a cross section of the LV in a circular shape

B. Once in a short axis view SLOWLY TILT the beam towards the apex of the heart

C. The notch will be positioned approximately at 5 o’clock (12 o ‘clock being the animal’s head)

2. Visible Structures

A. You should NOT see the papillary muscles

B. You should see the LV and RV

3. Required Images

A. Static Image

B. Video Clip

Right Parasternal Short Axis Images


Short Axis at Level of Papillary Muscles


A. From the short axis level of LV SLOWLY TILT the beam towards the base of the heart

until you can see the papillary muscles


A. You should see 2 papillary muscles within LV

3. Required Images

A. Static Image (x3)

B. Video Clip

C. M-mode Image (x3)

4. Measurements to obtain from these images

LVDd

LVDs

IVSd

IVSs

LVPWd

LVPWs

Note: More information on measurements is provided at the end of this document




Short Axis at Level of MV (fish mouth view)


A. From the level of the papillary muscles SLOWLY TILT the beam toward the base of the heart

B. You may need to also rotate the transducer SLIGHTLY


A. You should see the mitral valve

B. Should look like a fish mouth

3. Required Images

A. Static Image

B. Video Clip

C. M-mode Image



Short Axis at Level of Aortic Valve


A. From the level of the MV SLOWLY TILT the beam toward the base of the heart

B. NOTE: Sometimes you may need to move to a different intercostal space


A. You should see the AV, LA, RA,

TV, RV

3. Required Images

A. Static Image (x3)

B. Video Clip

C. Color Doppler Video - RVOT

4. Measurements to obtain from this image

Aortic root – leading edge to leading edge

LA – Left atrium at maximum dimension


Left Apical Long Axis Images

Long Axis 4 Chamber

1. Patient Position

A. Place the animal in a left lateral recumbent position on the cardiac table


A. The notch should be approximately 3 to 5 o’clock (with the animal’s head being 12 o’clock)

B. The transducer will be placed slightly caudal compared to a parasternal window


A. You should see LA, LV,

MV, RA, RV, and TV

4. Required Images

A. Static Image

B. Video Clip

C. Color Doppler Video of MV

D. Color Doppler Video of TV


Long Axis 5 Chamber (LV outflow tract)


A. From the apical 4 chamber view SLOWLY tilt the beam cranially


A. You should see LV, LVOT and AV clearly

B. You will also see RA, RV, TV, and LA

3. Required Images

A. Static Image

B. Video Clip

C. Color Doppler Video of AV/LVOT

Left Apical Long Axis Images


Echocardiography

Measurements

Training Module


TRAINING MODULE

ECHOCARDIOGRAPHY MEASUREMENTS

Cardiac measurements will be a very important part to a complete echocardiogram. We recommend that you

take your measurements in a short axis view with M-mode in canine patients and B mode in feline patients when

possible. B mode can also be used for measurements if you cannot produce a clear M mode image. Once these

direct measurements have been made, the ultrasound machine can then make calculations such as ejection

fraction. Each measurement should be taken 3 times

M-Mode Short Axis at the Level of Papillary Muscles

1. Obtain a clear short axis view at the level of the papillary muscles

2. Select the m-mode package and place the scan line perpendicular to the left ventricle central axis

3. Freeze the image once you have obtained a clear m-mode image

4. Select the measurement package (RV/LV) and measure the following:

A. IVSd - Intraventricular septum in diastole

B. LVDd - LV dimension in diastole

C. LVPWd - LV posterior wall in diastole

D. IVSs - Intraventricular septum in systole

E. LVDs - LV dimension in systole

F. LVPWd - LV posterior wall in systole

NOTE: If you star t with the IVSd, your machine will prompt you through your measurements. Select

IVSd and measure the septum when the LV appears the largest. Place your first caliper on the side of the right

ventricle and your second on the side of the left ventricle. Now you are ready for the LVDd. Drag your next

cursor down to the start of the left ventricle posterior wall. Once you place the cursor you are ready for the

LVPWd measurement. Place the caliper at the outer layer of the posterior wall.

Now select the IVSs and start the process over where the left ventricle is contracted (in systole).


2D Short Axis at the Level of Papillary Muscles

1. Obtain a clear short axis view at the level of the papillary muscles

2. Freeze the image once you have obtained a clear image

A. Scroll the image back using the cine frame/scroll bar until you can see true diastole

3. Select the measurement package and measure the following:

A. IVSd - Intraventricular septum in diastole

B. LVDd - LV dimension in diastole

C. LVPWd - LV posterior wall in diastole

4. Capture Image of measurements

5. Using the cine frame/scroll bar to locate true systole

6. Select the measurement package and measure the following:

A. IVSs - Intraventricular septum in systole

B. LVDs - LV dimension in systole

C. LVPWs - LV posterior wall in systole

7. Capture Image of measurements


Short Axis at the Level of AV 1. Obtain a clear short axis view at the level of the aortic valve

2. Select the measurement package (LA/AO) and measure the following from the 2D image

A. Aortic Root - leading edge to leading edge

B. LAD - left atrium dimension at maximum dimension

NOTE: We recommend using the Swedish method to obtain this measurement.

3. Other methods of capturing the LA/AO ratio can be seen below when suboptimal images of the short

axis 5 chamber view are available

NOTE: A separate m-mode measurement for the LA will be needed if you use m-mode because the

LA will not be seen at it’s largest dimension. A second short axis view focused on optimizing the

diameter of the LA is where you should create the measurement to assure an accurate LA:Ao.


COMMON ULTRASOUND TERMINOLOGY

Echogenicity

1. Is a term used to describe how a sound wave is reflected back to a transducer which can be used

to differentiate between tissue types

2. Hyperechoic

A. Increased echogenicity (meaning that the area of interest is a brighter shade of grey)

3. Hypoechoic

A. Decreased echogenicity (meaning that the area of interest is a darker shade of grey)

4. Anechoic

A. Means without echo (meaning the area of interest will appear black)

5. Homogenous

A. The are of interest shows an echogenicity that is uniform

6. Heterogenous

A. The area of interest show an echogenicity that is not uniform

B. Example: a mass that has both solid and cystic characteristics

Terms used when explaining how to locate anatomy

Medial

1. Towards the animal’s midline

Lateral

1. Away from midline (towards the left or right side of abdomen)

Cranial

1. Towards the animal’s head

Caudal

1. Away from the animals head (towards the tail)

Sliding the Transducer

1. Move the transducer

Rotating the Transducer

1. Rotate or twist the transducer while holding the probe in the same spot

Tilt the Beam of the Transducer

1. Hold the transducer in the same spot and point the transducer towards are of interest

2. Example: Tilt the beam cranial - without moving the probe, point towards the animal’s head

Fanning the Transducer

1. Hold the transducer in same spot and angle the transducer from the right to left

2. Example: Fan through the kidney after you have obtained a midline image - angle the probe

from the medial to lateral side while holding the transducer in the same spot


Optimizing your images

Try to make the organ you are imaging fill at least half of your screen. You

want to be able to see any subtle changes:

1. You can do this by changing your depth while scanning live.

2. You can also do this by changing your zoom.

3. You can do this after your image is frozen by changing your zoom.

If your images are too dark:

1. Try increasing your GAIN (higher number)

2. Try decreasing your frequency (lower number)

3. Try a frequency that does not have an H in front of it. (Harmonics)

4. Try a different TGC .

5. Try a different map.

6. Make sure that you are not over hair, over a rib, use more gel, try a different window. Try to

avoid gas.

If your images are too light:

1. Try decreasing your GAIN (lower number)

2. Try increasing your Frequency (higher number)

3. Try using a Frequency with an H in front of the number (Harmonics)

4. Try changing your TGC.

5. Try changing your MAP

If you are having problems imaging an organ in the area where you think it should be:

1. If you apply too much pressure to some organs (such as a bladder or spleen in cats), you can

smash the organ or displace it and it will move out of your field of view. Try a lighter pressure.

2. If you apply too little pressure to some organs (such as the liver or right kidney in dogs) you may

not be able to see the organ because it is too deep. Try a more intense pressure. Sometimes you

may need to sedate the animal to apply more pressure.

3. Try moving to a different area and angle back toward the organ. Sometimes you can avoid gas,

or use another organ to enhance your window.

4. Try changing the position of the animal. (i.e. Move from laying on back to laying on side) . You

can also try scanning with the animal standing up. This will change gas patterns and may “open

up” a window to scan.

5. If there is too much movement, (such as from a panting dog), try holding the mouth shut to settle

down the breathing. If you are looking for organs such as adrenal glands, you may need to

sedate the animal.

6. If possible, have the animal fast for 8 hours. This will minimize gas in in the GI tract and enable

you to see more anatomy.

Document Authored By:

Dr. Brian J. Huber, DVM

Janet Huber, RDMS, RVT, RT

Stephanie Merrell, RDMS, RVT, RCDS

Dr. Brian A. Poteet, MS, DVM

Date post:	06-Jul-2018
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Echocardiography - Wendy Blountwendyblount.com/sono-lufkin/Oncura-EchocardiographyManual.pdf ·...

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