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studies for example the differentiation of mild moderate and severe valvular disease is based upon measured criteria 8 another example is the estimation of heart function by the left ventricular ejection fraction lvef has vast uses including classification of heart failure and cut offs for implantation of implantable cardioverter defibrillators citation needed health societies do not recommend routine testing when the patient has no change in clinical status or when a physician is unlikely to change care for the patient based on the results of testing 7 a common example of overuse of echocardiography when not indicated is the use of routine testing in response to a patient diagnosis of mild valvular heart disease 9 in this case patients are often asymptomatic for years before the onset of deterioration and the results of the echocardiogram would not result in a change in care without other change in clinical status 9 echocardiography has a vast role in pediatrics diagnosing patients with valvular heart disease and other congenital abnormalities an emerging branch is fetal echocardiography which involves echocardiography of an unborn fetus 10 types edit transthoracic echocardiogram edit main article transthoracic echocardiogram a standard echocardiogram is also known as a transthoracic echocardiogram tte or cardiac ultrasound and it is used for rapid evaluation of a patient at their bedside 11 12 in this case ultrasound gel is applied to the chest wall to help transmitt the ultrasound waves 13 then the echocardiography transducer or probe is placed on the chest wall or thorax of the subject and images are taken through the chest wall this is a non invasive highly accurate and quick assessment of the overall function of the heart transthoracic echocardiography can display structure of heart chambers myocardial motion and valvular function in real time and is widely used to access a variety of cardiovascular diseases such as ventricular systolic dysfunction valvular heart disease and pericardial disease 14 but although tte is a non invasive and widely used examination method its image quality can be influenced by body fat thickness of chest and other factors tte utilizes several windows to image the heart from different perspectives each window has advantages and disadvantages for viewing specific structures within the heart and typically numerous windows are utilized within the same study to fully assess the heart parasternal long and parasternal short axis windows are taken next to the sternum the apical two three four chamber windows are taken from the apex of the heart lower left side and the subcostal window is taken from underneath the edge of the last rib 15 tte utilizes m mode 2d and 3d ultrasounds time is implicit and not included from the different windows these can be combined with pulse wave or continuous wave doppler to visualize the velocity of blood flow through the left ventricle and structure movements images can be enhanced with contrast that are typically some sort of micro bubble suspension that reflect the ultrasound waves 16 transesophageal echocardiogram edit this section needs more reliable medical references for verification or relies too heavily on primary sources please review the contents of the section and add the appropriate references if you can unsourced or poorly sourced material may be challenged and removed find sources echocardiography news newspapers books scholar jstor march 2023 main article transesophageal echocardiogram a transesophageal echocardiogram is an alternative way to perform an echocardiogram a specialized probe containing an ultrasound transducer at its tip is passed into the patient s esophagus via the mouth allowing image and doppler evaluation from a location directly behind the heart it is most often used when transthoracic images are suboptimal and when a clearer and more precise image is needed for assessment or in specific conditions such as being in a critical condition such as having low oxygen levels or needing heart surgery 17 because the esophagus is located behind and close to the heart this method can provide higher resolution images than transthoracic echocardiography tte 18 this test is performed in the presence of a cardiologist anesthesiologist registered nurse and ultrasound technologist during the examination patients need to be fasting before the examination begins the doctor will administer local anesthesia to patient s throat and administer sedative drugs if necessary 19 tee is invasive during the examination a flexible scope with an ultrasound probe will be slowly inserted into the esophagus the position and angle of the probe can be adjusted as needed to obtain different angle of view additionally modern multiplane tee probes use transducer elements to generate a two dimension plane 20 21 and the ultrasound plane can be rotated electronically to permit an additional dimension to optimize views of the heart structures often movement in all of these dimensions is needed tee can be used as stand alone procedures or incorporated into catheter or surgical based procedures for example during a valve replacement surgery the tee can be used to assess the valve function immediately before repair replacement and immediately after this permits revising the valve mid surgery if needed to improve outcomes of the surgery 22 stress echocardiography edit main article cardiac stress test a stress echocardiogram also known as a stress echo uses ultrasound imaging of the heart to assess the wall motion in response to physical stress first images of the heart are taken at rest to acquire a baseline of the patient s wall motion at a resting heart rate the patient then walks on a treadmill or uses another exercise modality to increase the heart rate to his or her target heart rate or 85 of the age predicted maximum heart rate 220 patient s age finally images of the heart are taken at stress to assess wall motion at the peak heart rate a stress echo assesses wall motion of the heart it does not however create an image of the coronary arteries directly ischemia of one or more coronary arteries could cause a wall motion abnormality which could indicate coronary artery disease the gold standard test to directly create an image of the coronary arteries and directly assess for stenosis or occlusion is a cardiac catheterization a stress echo is not invasive and is performed in the presence of a licensed medical professional such as a cardiologist and a cardiac sonographer 23 a systematic review and meta analysis published in heart in 2024 studied the long term capabilities of stress echocardiography being used to identify coronary artery disease data were collected from over 16 000 patients from a total of six clinical trials the results from the meta analysis show that patients with a positive stress echocardiography test indicative of reduced blood flow to the heart from coronary arteries had higher annual rates of major adverse cardiovascular events mace and all cause mortality than those with negative results the annual mace rate was 1 99 for patients with a positive test compared to 1 54 in those with negative tests the mortality rates for the patients were 1 68 and 1 02 respectively the results from the meta analysis show that stress echocardiography may be able to provide predictive long term information and can be used for better risk assessment in patients with coronary artery disease 24 intracardiac echocardiography edit main article intracardiac echocardiogram intracardiac echocardiography ice is specialized form of echocardiography that uses catheters to insert the ultrasound probe inside the heart to view structures from within the heart ice is often used as a part of the cardiac procedure of crossing the interatrial septum with a transseptal puncture to permit catheter access from the right atrium to the left atrium alternative access to the left heart would be retrograde through the aorta and across the aortic valve into the left ventricle 25 ice has the benefit over transthoracic echocardiography in that an operator who is performing a sterile procedure can also operate the ice catheter and it is not limited to visibility problems that can arise with transthoracic or transesophageal echo though there are image quality limitations due to size constraints of the probe being limited to a catheter 26 ice is often inserted through the femoral vein and into the right atrium from the right atrium visualization of the interatrial septum all four cardiac chambers all four valves and the pericardial space for an effusion can be readily visualized it can also be advanced across the atrial septum into the left atrium to visualize the left atrial appendage during left atrial appendage occlusion device deployment 27 according to singleton osorio electrophysiologic studies and catheter ablation have been done using fluoroscopic guidance but have recently transitioned to using electroanatomic mapping eam and ice to stop using fluoroscopy eam and ice allow for three dimensional accurate images of the chamber being imaged guidewires and catheter tissue interfaces this combination has replaced fluoroscopy for electrophysiologic procedures 28 intravascular ultrasound edit coronary artery ivus with lumen inside yellow line and atherosclerotic plaque in green intravascular ultrasound ivus is an intravascular technique that uses a catheter to insert the ultrasound probe inside blood vessels this is commonly used to measure the size of blood vessels and to measure the internal diameter of the blood vessel for example this can be used in a coronary angiogram to assess the narrowing of the coronary artery 29 ivus images the inside of blood vessels so it allowed direct observation of the inside of vessels during the examination a catheter with ultrasound probe is inserted into a blood vessel through the femoral or radial artery then the probe can be pushed to the target vessel location such as coronary artery when probe reached it emits ultrasound waves and received reflected echoes as the catheter is retraced in a controlled manner then an internal map can be generated to see the contour of the vessel and its branches 30 modes edit this section has multiple issues please help improve it or discuss these issues on the talk page learn how and when to remove these messages this section needs expansion you can help by adding missing information february 2023 this section does not cite any sources please help improve this section by adding citations to reliable sources unsourced material may be challenged and removed february 2023 learn how and when to remove this message learn how and when to remove this message the various modes describe how the ultrasound crystals are used to obtain information these modes are common to all types of echocardiography 31 32 a mode edit a scan or one dimensional ultrasound represents over half the standard echo exam the a stands for amplitude which means the echocardiogram is the processed amplitude versus time produced as an output from the receiver of ultrasound for example it is how aortic stenosis valve area or any obstruction it is also how pressures are calculated in the heart such as right ventricle systolic pressure rvsp it is usually used in the form of doppler measurements there are two forms pulse and continuous pulsed allows velocities to be calculated in a specific place but has a limited velocity range can be used continuous wave allows the velocity to be measured from zero to the fastest blood velocities a diseased heart can generate however it cannot tell you where in the a scan the high velocity is coming from continuous wave would be used to calculate aortic stenosis because you know the high velocity is coming from the stenosis region pulsed would be used to find a ventricular septal defect where there should be no velocity across the septum and the pulsed tells you the location 31 b mode edit b mode is also known as brightness mode it is based on the conversion of a mode ultrasound signals into a two dimensional grayscale image where stronger signal appear brighter and weaker signals appear darker multiple signal lines swept across the heart can build a cross sectional image of it in real time 31 m mode edit m mode uses a single ultrasound line to obtain a one dimensional view of all the structures that reflect the ultrasound wave the ultrasounds in m mode can capture the heart in systole and diastole one disadvantage of m mode is that it only uses one ultrasound line which is not able to move from the tip of the transducer 31 32 m mode imaging being used to interrogate the mitral valve from the parasternal long axis view strain rate imaging deformation echocardiography edit main article strain rate imaging strain rate imaging utilizing echocardiography is a method that can be used to detect abnormalities in the heart strain rate imaging measures either regional systolic deformation strain or the rate of regional deformation strain rate the methods used are either tissue doppler or speckle tracking echocardiography according to smiseth et al 2024 one clinical application of strain rate imaging is using longitudinal strain instead of using ejection fraction for diagnosing mild systolic dysfunction 33 three dimensional echocardiography edit three dimensional echocardiography also known as four dimensional echocardiography when the picture is moving is possible using a matrix array ultrasound probe and an appropriate processing system it enables detailed anatomical assessment of cardiac pathology particularly valvular defects 34 and cardiomyopathies 35 the ability to slice the virtual heart in infinite planes in an anatomically appropriate manner and to reconstruct three dimensional images of anatomic structures make it unique for the understanding of the congenitally malformed heart 36 real time three dimensional echocardiography can be used to guide the location of bioptomes during right ventricular endomyocardial biopsies placement of catheter delivered valvular devices and in many other intraoperative assessments 37 three dimensional echocardiography technology may feature anatomical intelligence or the use of organ modeling technology to automatically identify anatomy based on generic models all generic models refer to a dataset of anatomical information that uniquely adapts to variability in patient anatomy to perform specific tasks built on feature recognition and segmentation algorithms this technology can provide patient specific three dimensional modeling of the heart and other aspects of the anatomy including the brain lungs liver kidneys rib cage and vertebral column 38 myocardial contrast echocardiography edit myocardial contrast echocardiography mce is a technique that has been developed over the past three decades that uses microbubbles also called ultrasound enhancing agents uea to improve cardiac imaging uea improv...
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