Echocardiogram Procedure

We should take care of our heart, body, and mind to live a long and healthy life. In this blog, we will discuss the important diagnostic test that helps us evaluate the function and structure of the heart. An echocardiogram is one such test that doctors rely on the most to assess heart conditions.

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This blog will help you know everything you need to know about the echocardiogram procedure, including what it is, why it is done, and how it is performed. What to expect before, during, and after the procedure.

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What is an Echocardiogram?

An echocardiogram (echo) is a non-invasive procedure that does not breach the skin. To record an echocardiogram, sound waves are transmitted through a transducer. These waves have a frequency too high to be heard and are therefore known as ultrasounds. 

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The transducer, a handheld device, when placed on the chest at specific locations and angles, bounces off or echoes to display heart structures. These are the acoustic windows. These sound waves then reach the computer, allowing it to create moving images of various heart structures on the computer screen.

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 2D echo is commonly referred to as a transthoracic echocardiogram (TTE). Most 2D echos are performed by the TTE method. In clinical settings, 2D echocardiography (2D echo) and transesophageal echocardiography (TEE) are often used interchangeably.

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Various types of echocardiograms

• Trans thoracic echocardiogram (TTE): It is the most common type and is performed by placing the transducer on the chest.

• Transesophageal echocardiogram (TEE): The transducer is inserted into the oesophagus for clearer images of the posterior heart.

• A stress echocardiogram is conducted during or after the exercise to assess the functions of the heart under stress.

• Doppler echocardiogram: It measures the speed and direction of blood flow in the heart.

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When is it Advisable to Undergo a 2d Echo?

A 2-D echo is advised for people who have:-

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• Chest pain, shortness of breath, dizziness, and irregular heartbeat.

• Those who have a family history of heart disease or are taking treatment for various heart conditions.

• People with comorbidities like diabetes and hypertension are at risk of heart complications.

• Individuals who need the test before and after a surgical heart procedure.

How does an Echocardiogram help to diagnose heart conditions?

The echocardiogram evaluates the heart's function and structure. It evaluates the signs and symptoms that suggest:-

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• Complications resulting from blocked arteries (atherosclerosis), such as heart failure or vascular diseases, can be detected by Doppler ultrasound.

• Cardiomyopathy detects enlargement of the heart, due to thick or weak heart muscles.

• Congenital heart defects: Defects that arise in the heart during the formation of the foetus, for example, a ventricular septal defect or a hole in the heart wall between the two lower chambers of the heart, and also atrial septal defects.

• Heart failure weakens or stiffens the heart muscle. The heart is unable to pump blood efficiently, which causes fluid buildup in blood vessels and lungs, resulting in swelling in the feet, ankles, and other parts of the body. It also occurs due to coronary artery disease and high blood pressure.

• Aneurysm: A rupture occurs when the aorta, a large artery that carries oxygenated blood to the body, widens or weakens.

• Heart valve disease: A defect in one or more of the heart valves can prevent blood flow through the heart or out of the lungs and body. These valves can even become leaky, allowing blood to leak backward. An echocardiogram can also detect infections in the heart valves.

• Cardiac tumours: They can occur on the outer surface of the heart, involving one or more chambers or the myocardial tissue, but require CT and MRI for complete evaluation.

• Pericarditis: inflammation of the pericardial sac around the heart.

• Pericardial effusion or tamponade. The sac around the heart can become filled with fluid, blood, or infection, which compresses the heart and prevents it from beating and pumping blood efficiently. Dizziness, lightheadedness, and a drop in blood pressure are its consequences. Cardiac tamponade is a severe form of pericardial effusion.

• Atrial or ventricular septal wall defects: The right and left chambers of the heart can develop defects due to trauma at various stages of development, causing poor blood flow, thus increasing the risk of stroke. 

• Shunts are abnormal circulatory pathways between chambers or vessels occurring in congenital diseases like atrial or ventricular septal defects. Other modalities, such as bubble contrast studies, aid in their identification.

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Echocardiogram Procedure

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Preparation

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Before the test:-

• There are no restrictions on what you can eat and drink before the echo procedure.

• You will need to wear a hospital gown and remove clothing from your waist up.

• Echo is usually done in dark rooms because it makes images clearer to the sonographer.

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During the test:-

• Position: You will be asked to lie on your left side, which brings the heart closer to the chest wall for better images.

• Gel application: A water-based gel is used on the chest for smooth transmission of the ultrasound waves.

• Probe placement: The sonographer uses a handheld device called the transducer on the chest, which sends and receives the sound waves.

• Image capture: As the probe moves across the chest, the echoes from the heart structure are picked up and converted to real-time images on the monitor.

• Multiple views: The sonographer takes images of the heart from different angles.
  
  • long axis
  • short axis
  • apical (from the bottom of the heart)
  • subcostal (below the ribs).
• It takes 30 to 45 minutes to complete the process

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After the test:-

• The gel is wiped off, you can get dressed, and resume normal activities.

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Cardiac anatomy

Understanding the anatomy of the heart enables us to interpret ultrasound views accurately. The four chambers in the heart, the right atrium, right ventricle, left atrium, and left ventricle, are separated by their respective valves, the tricuspid valve, pulmonic valve, mitral valve, and aortic valve.

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With a transthoracic echocardiogram, it is easy to observe these structures. Still, while doing it, we must remember that the heart is more medially (towards the midline) located than we presume.

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Echo Imaging Basics

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Cardiac machine placement

Place the ultrasound machine on the patient’s right side since it is easy to manipulate the ultrasound buttons with your left hand as you do the scan with your right hand.

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Transducers

A transducer is an electronic device that converts energy from one form to another. Transthoracic cardiography uses the ultrasound wand, a handheld device that emits sound waves that penetrate the chest and are reflected off the heart structures.

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 The role of transducers

• The transducer generates high-frequency sound waves, a form of ultrasound.

• The sound waves travel through the chest and tissues and are reflected after encountering different structures in the heart.

• It receives and captures reflected sound waves.

• The machine analyses the echoes and creates images on a screen.

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Transducers in ultrasound machines use the piezoelectric effect to generate an electric charge when subjected to mechanical stress, like sound waves. It is the transducers that convert electrical signals into sound waves to visualise the heart and other structures.

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Choosing the right tool

The probe or transducer is placed on the skin, and it sends and receives sound waves.

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Different probes are used for different body parts:-

• Cardiac (phased array): They are small and used for the heart.

• Abdominal (curvilinear): Wider for organs like the liver or kidneys.

• Vascular (linear): flat for veins, arteries, or muscles.

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High-frequency probes give detailed images of shallow areas; low-frequency probes go deeper but provide less detail.

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Imaging modes

Ultrasound machines offer various imaging modes:-

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• B-mode 2-D Standard black and white images.

• M mode shows motion over time (useful for the heart).

• Doppler modes show blood flow.
  
  • Colour Doppler uses red and blue to show direction.
  • Power Doppler detects tiny flows.
  • Pulsed/Continuous Doppler measures flow speed.

Each mode gives different information, whether it's movement, blood flow, or structure.

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Taking Pictures:-

Ultrasound machines have knobs and buttons to adjust how images look.

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• Depth zoom in or zoom out for the brightness. It makes the picture light or dark.

• Freeze pauses the picture so that you can look closely.

• Measure adds lines and measurements for the image.

• Save keeps a still image or video clip.

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These tools help you get a clear picture of what is happening inside the body.

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Heart Orientation and Access Points

Axes of the heart

 The images obtained with echocardiography are of the heart itself. There are two major axes of the heart.

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• Long axis: The Long axis is an imaginary line from the apex of the heart through the centre of the tricuspid/ mitral valve.

• Short axis: It is perpendicular to the long axis and shows the heart in cross-section.

Cardiac ultrasound views/windows

The five basic ultrasound windows of the heart are:

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• Parasternal long axis.

• Parasternal short axis.

• Apical 4-chamber.

• Subcostal.

• IVC view.

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Parasternal long axis (PSLA) view

The view that gives the first assessment of:

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• General condition of the heart.

• Ejection fraction.

• Overall left and right ventricular sizes.

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The probe is placed such that it points towards the right shoulder at the 4^th intercostal space, which coincides with the nipple line for males or the inframammary fold to the sternum in females. 

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Structures visible in the parasternal long-axis view

• Right ventricle RV.

• Left ventricle LV.

• Left atrium LA.

• Aortic Valve AV.

• Mitral valve MV.

• Aorta AO.

• Descending Aorta DA.

• Pericardium.

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Always remember in 

In the parasternal long-axis view, the left ventricle is on the left side of the screen. Optimize the different chambers of the heart and their depth to ensure visibility of the descending aorta.

Parasternal short access view (PSSA) in an echocardiogram

This view looks at the heart to show the heart muscle and valves in cross-section or circular pieces. For this view, the probe is placed on the chest and turned sideways, usually from the left side. From here, we can look at different layers of the heart.

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1. Mid papillary level 

• It allows us to see the heart muscles.

• It shows the left and right ventricles as circular images of the heart.

• It assesses how well the heart is pumping (ejection fraction) and if there are any weak spots in the muscle.

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2. Mitral valve level, the fish mouth view

• Higher up, it shows the mitral valve.

• The valve resembles a fish's mouth opening and closing.

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3. Aortic valve level - the Mercedes-Benz sign

• At higher angles of the probe, we see the aortic valve and parts of the right and left atria.

• Three leaflets of the aortic valves resemble the Mercedes-Benz logo in this view.

• We can detect valve problems like narrowing (stenosis) or leakage (regurgitation).

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These views provide us with detailed information about the heart's functioning, its valves, and their movement, as well as any potential damage or disease.

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Apical view in an echocardiogram

When we look at the heart from its tip, it is known as the Apical view.

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It tells us

• How the heart fills and empties.

• Leaky valves.

• If the heart is pumping enough blood.

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Other apical views are

1. Apical 4-chamber view (A4C)

• It shows all four chambers of the heart in one frame, and the mitral and tricuspid valves.

• The ultrasound probe is near the tip of the heart, tilting towards the feet.

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2. Apical 5-chamber view A5C

• Besides the four chambers, the view adds the aortic valve, where blood exits the heart.

• Starting from a 4-chamber view, the probe is tilted more towards the feet

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3. Sometimes, an error occurs when tilting the probe, and the Mistaken view or the coronary sinus view shows a hole between the top chambers of the heart.

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This view allows us to assess

• If the chambers are working.

• Valves are opening and closing properly.

• If the blood flow is in the right direction.

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Subcostal view

• It is helpful for people with lung diseases or during emergencies like trauma.

• You may be asked to lie on your back with knees slightly bent, which relaxes the belly muscles.

• Pointing the probe towards the left gives a clear picture of the heart.

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It allows us to see

• 4 chambers of the heart.

• Tricuspid and mitral valves.

• The sac (pericardium) around the heart.

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In this view, the liver acts like a window for the sound waves, but if it is pointed too far, the stomach and bowel gases can block the image. 

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Risks and Complications of he 2-D Echo Test

A 2-D echocardiogram is one of the safest tools in medicine. It is non-invasive and uses ultrasounds instead of radiation. Mild discomfort may be experienced during the procedure when the technician presses the transducer against the chest, as this allows clear images. 

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Conclusion

A 2-D echo is an important test for diagnosing and maintaining a healthy heart. It provides us with information about the heart's structure and the flow of blood through it. Gauze is just a call away if anyone requires an echocardiogram. With its AI-powered solutions and expert cardiologists, they offer the heart care you deserve.