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Physical Basics echocardiography

Ultrasound is the propagation of longitudinal wave vibrations in an elastic medium with a frequency of >20,000 vibrations per second. An ultrasonic wave is a combination of successive compressions and rarefaction, and a complete wave cycle consists of compression and one rarefaction. The frequency of an ultrasound wave is the number of complete cycles over a certain period of time. The unit of frequency of ultrasonic oscillations is the hertz (Hz), which is one oscillation per second. IN medical practice Ultrasound oscillations are used with a frequency of 2 to 30 MHz, and accordingly in echocardiography - from 2 to 7.5 MHz.

The speed of propagation of ultrasound in media with different densities is different; V soft tissues a person reaches 1540 m/s. IN clinical studies Ultrasound is used in the form of a beam that propagates in a medium of varying acoustic density and, when passing through a homogeneous medium, that is, a medium having the same density, structure and temperature, propagates in a straight line.

The spatial resolution of the ultrasound diagnostic method is determined by the minimum distance between two point objects at which they can still be distinguished in the image as separate points. The ultrasound beam is reflected from objects whose size is at least 1/4 of the ultrasound wavelength. It is known that the higher the frequency of ultrasonic oscillations, the narrower the beam width and the lower its penetrating ability. The lungs are a significant obstacle to ultrasound propagation because they have the smallest half-attenuation depth of all tissues. Therefore, transthoracic echoCG (TT-echoCG) study is limited to the area where the heart lies towards the anterior chest wall and not covered by the lungs.

To obtain ultrasonic vibrations, a sensor with special piezoelectric crystals is used, which converts electrical pulses into ultrasonic pulses and vice versa. When an electrical impulse is given, the piezoelectric crystal changes its shape and, when straightened, generates an ultrasonic wave, and the reflected ultrasonic vibrations perceived by the crystal change its shape and cause the appearance of an electric potential on it. These processes make it possible to simultaneously use an ultrasonic piezo-crystal sensor both as a generator and a receiver of ultrasonic waves. Electrical signals generated by the piezoelectric crystal of the sensor under the influence of reflected ultrasound waves are then converted and visualized on the device screen in the form of echograms. As is known, parallel waves are reflected better and that is why objects located in the near zone are more clearly visible in the image, where the intensity of radiation and the probability of propagation of parallel rays perpendicular to the interfaces are higher.

You can adjust the length of the near and far zones by changing the radiation frequency and the radius of the ultrasonic sensor. Today, with the help of converging and scattering electronic lenses, they artificially lengthen the near zone and reduce the divergence of ultrasonic beams in far zone, which can significantly improve the quality of the resulting ultrasound images.

In the clinic, both mechanical and electronic sensors are used for echocardiography. Sensors with an electron phase grating, having from 32 to 128 or more piezoelectric elements built in the form of a grating, are called electronic. During an echoCG study, the sensor operates in the so-called pulse mode, in which the total duration of the ultrasound signal emission is<1% общего времени работы датчика. Большее время датчик воспринимает отраженные УЗ-сигналы и преобразует их в электрические импульсы, на основе которых затем строится диагностическое изображение. Зная скорость прохождения ультра звука в тканях (1540 м/с), а также время движения ультразвука до объекта и обратно к датчику (2.t), рассчитывают расстояние от датчика до объекта.

The relationship between the distance to the object of study, the speed of propagation of ultrasound in tissues and time underlies the construction of an ultrasound image. Pulses reflected from a small object are recorded in the form of a point, its position relative to the sensor in time is displayed by a scan line on the device screen. Stationary objects will be represented by a straight line, and changing the depth of the position will cause a wavy line to appear on the screen. This method of recording echo signals is called one-dimensional echocardiography. In this case, the distance from the heart structures to the sensor is displayed along the vertical axis on the echocardiograph screen, and the time scale is displayed along the horizontal axis. The sensor for one-dimensional echocardiography can send pulses with a frequency of 1000 signals per second, which provides high temporal resolution of the M-mode study.

The next stage in the development of the echocardiography method was the creation of devices for two-dimensional imaging of the heart. In this case, structures are scanned in two directions - both in depth and horizontally in real time. When performing a two-dimensional echoCG, the cross-section of the structures under study is displayed within a sector of 60-90° and is constructed by many points that change position on the screen depending on the change in the depth of the location of the structures under study in time relative to the ultrasound sensor. It is known that the frame rate of two-dimensional echoCG images on the screen of an echoCG device is usually from 25 to 60 per second, which depends on the scanning depth.

One-dimensional echocardiography

One-dimensional echocardiography is the very first method of cardiac ultrasound in history. The main distinguishing feature of M-mode scanning is its high temporal resolution and the ability to visualize the smallest features of cardiac structures in motion. Currently, M-mode research remains a significant addition to the main two-dimensional echoCG.

The essence of the method is that a scanning beam focused on the heart, reflected from its structures, is received by the sensor and, after appropriate processing and analysis, the entire block of received data is reproduced on the device screen in the form of an ultrasound image. Thus, on an echogram in M-mode, the vertical axis on the echocardiograph screen displays the distance from the heart structures to the sensor, and the horizontal axis displays time.

To obtain the main echoCG sections for one-dimensional echoCG, ultrasound is performed in the parasternal position of the sensor to obtain an image along the long axis of the LV. The sensor is placed in the third or fourth intercostal space 1–3 cm to the left of the parasternal line (Fig. 7.1).

Rice. 7.1. The direction of the ultrasound beam in the main slices of one-dimensional echocardiography. Hereinafter: Ao - aorta, LA - left atrium, MK - mitral valve

When the ultrasound beam is directed along line 1 (see Fig. 7.1), it is possible to estimate the size of the chambers, the thickness of the walls of the ventricles, and also calculate indicators characterizing the contractility of the heart (Fig. 7.2) using echocardiography visualized on the screen (Fig. 7.3). The scanning beam should cross the interventricular septum perpendicularly and then pass below the edges of the mitral leaflets at the level of the papillary muscles.

Rice. 7.2. Scheme for determining chamber sizes and thickness. Scheme for determining chamber sizes and heart wall thickness in M-mode. Hereinafter: RV - pancreas; LV - left ventricle; RA (RA) - right atrium; LP (LA) - left atrium; IVS - interventricular septum; AK - aortic valve; RVOT - outflow tract of the pancreas; LVOT - left ventricular outflow tract; dAo - aortic diameter; CS - coronary sinus; ZS - posterior wall (of the ventricle); PS - front wall; EDR - LV end-diastolic size; ESR - LV end-systolic size; E - maximum early diastolic opening; A - maximum opening during atrial systole; MSS - mitral-septal separation

Rice. 7.3. EchoCG image at the level of the papillary muscles

Based on the resulting image based on the EDR and ESR of the LV, its EDV and ESR are calculated using the Teicholtz formula:

7 D 3

V = -------,

2.4+D

Where V - LV volume, D - LV anteroposterior size.

Modern echocardiographs have the ability to automatically calculate indicators of LV myocardial contractility, among which EF, fractional shortening (FS), and the velocity of circular shortening of myocardial fibers (Vcf) should be highlighted. The above indicators are calculated using the formulas:

where dt - the time of contraction of the posterior wall of the LV from the beginning of the systolic rise to the apex.

The use of M-mode as a method for determining the size of cavities and the thickness of the walls of the heart is limited due to the difficulty of perpendicular scanning relative to the walls of the heart.

To determine the size of the heart, the most accurate method is sectoral scanning (Fig. 7.4), the technique of which is described below.

Rice. 7.4. Scheme for measuring heart chambers with two-dimensional echocardiography

Normal M-mode measurement values ​​for adults are given in Appendix 7.2.

One should also take into account the distortion of some indicators of measurements made when scanning in M-mode in patients with impaired segmental contractility of the LV myocardium.

In this category of patients, when calculating EF, the contractility of the posterior wall of the LV and the basal segments of the interventricular septum will be taken into account, and therefore the calculation of global contractile function in these patients is carried out using other methods.

Researchers encounter a similar situation when calculating FU and Vcf. Based on this, the indicators of EF, FU and Vcf in patients with segmental disorders are not used when performing one-dimensional echoCG.

At the same time, when performing one-dimensional echoCG, it is possible to identify signs that indicate a decrease in the contractility of the LV myocardium. These signs include premature opening of the aortic valve, when the latter opens before the QRS complex is recorded on the ECG, an increase of more than 20 mm in the distance from point E (see Fig. 7.2) to the interventricular septum, as well as premature closure of the mitral valve.

Using the measurement results at a given position of the scanning beam with one-dimensional echocardiography, using the Penn Convention formula, it is possible to calculate the mass of the LV myocardium:

LV myocardial mass (g) = 1.04 [(EDR + IVS + TZS) 3 - EAD 3 ] - 13.6,

Where EDR - end-diastolic dimension of the LV, IVS - thickness of the interventricular septum, TZS - thickness of the posterior wall of the LV.

When changing the angle of the sensor and scanning the heart along line 2 (see Fig. 7.1), the walls of the RV, IVS, anterior and posterior leaflets of the mitral valve, as well as the posterior wall of the LV are clearly visualized on the screen (Fig. 7.5).

Rice. 7.5. One-dimensional echocardiography scan at the level of the mitral valve leaflets

The mitral valve leaflets perform characteristic movements in diastole: the anterior one is M-shaped, and the posterior one is W-shaped. In systole, both leaflets of the mitral valve produce an obliquely ascending line. It should be noted that normally the amplitude of movement of the posterior leaflet of the mitral valve is always less than that of its anterior leaflet.

Continuing to change the angle of inclination and directing the sensor along line 3 (see Fig. 7.1), we obtain an image of the wall of the RV, the interventricular septum and, unlike the previous position, only the anterior leaflet of the mitral valve, making an M-shaped movement, as well as the wall of the left atrium .

A new change in the angle of the sensor along line 4 (see Fig. 7.1) leads to visualization of the RV outflow tract, aortic root and left atrium (Fig. 7.6).

In the resulting image, the anterior and posterior walls of the aorta appear as parallel wavy lines. The cusps of the aortic valve are located in the lumen of the aorta. Normally, the leaflets of the aortic valve diverge in LV systole and close in diastole, forming a closed curve in the form of a box in motion. Using this one-dimensional image, the diameter of the left atrium, the size of the posterior wall of the left atrium, and the diameter of the ascending aorta are determined.

Rice. 7.6. One-dimensional echocardiography scan at the level of the aortic valve leaflets

Two-dimensional echocardiography

Two-dimensional echocardiography is the main method of ultrasound diagnostics in cardiology. The sensor is placed on the anterior chest wall in the intercostal spaces near the left edge of the sternum or under the costal arch or in the jugular fossa, as well as in the area of ​​the apical impulse.

Basic echocardiographic approaches

Four main ultrasound approaches for cardiac imaging have been identified:

1) parasternal (circumsternal);

2) apical (apical);

3) subcostal (subcostal);

4) suprasternal (suprasternal).

Parasternal long axis approach

The ultrasound slice from the parasternal access along the long axis of the LV is the main one; the echocardiography study begins with it, and the one-dimensional scanning axis is oriented along it.

Parasternal access along the long axis of the LV makes it possible to identify pathology of the aortic root and aortic valve, subvalvular obstruction of the LV outlet, assess LV function, note movement, range of motion and thickness of the interventricular septum and posterior wall, determine structural changes or dysfunction of the mitral valve or its supporting structures, identify dilatation of the coronary sinus, evaluate the left atrium and identify a space-occupying formation in it, as well as conduct a quantitative Doppler assessment of mitral or aortic insufficiency and determine muscular defects of the interventricular septum using the color (or pulse) Doppler method, as well as measure the magnitude of the systolic pressure gradient between the chambers hearts.

For correct visualization, the sensor is placed perpendicular to the anterior chest wall in the third or fourth intercostal space near the left edge of the sternum. The scanning beam is directed along a hypothetical line connecting the left iliac fossa and the middle of the right clavicle. The heart structures closest to the sensor will always be visualized at the top of the screen. Thus, on top of the echoCG there is the anterior wall of the RV, then the interventricular septum, the LV cavity with papillary muscles, chordae tendineae and mitral valve leaflets, and the posterior wall of the LV is visualized in the lower part of the echoCG. In this case, the interventricular septum passes into the anterior wall of the aorta, and the anterior mitral cusp into the posterior wall of the aorta. At the root of the aorta, movement of the two leaflets of the aortic valve is visible. The right coronary cusp of the aortic valve is always superior, and the inferior cusp can be either left coronary or non-coronary, depending on the scanning plane (Fig. 7. 7).

Normally, the movement of the aortic valve leaflets is not clearly visible because they are quite thin. In systole, the aortic valve leaflets are visible as two parallel strips adjacent to the walls of the aorta, which in diastole can only be seen in the center of the aortic root at the point of closure. Normal visualization of the aortic valve leaflets occurs when they are thickened or in individuals with a good echo window.

Rice. 7.7. Long axis of the LV, parasternal approach

The mitral valve leaflets are usually well visualized and make characteristic movements in diastole, and the mitral valve opens twice. With active blood flow from the LV atrium in diastole, the mitral leaflets diverge and hang into the LV cavity. Then the mitral valves, approaching the atrium, partially close after the end of the early diastolic filling of the ventricle with blood, which is called early diastolic closure of the mitral valve.

During left atrium systole, blood flow for the second time produces a diastolic opening of the mitral valve, the amplitude of which is less than the early diastolic one. During ventricular systole, the mitral valve leaflets close, and after a phase of isometric contraction, the aortic valve opens.

Normally, when visualizing the LV along the short axis, its walls form a muscular ring, all segments of which thicken evenly and approach the center of the ring in ventricular systole.

With parasternal access along the long axis, the LV looks like an equilateral triangle, in which the vertex is the apex of the heart, and the base is a conventional line connecting the basal parts of the opposite walls. As they contract, the walls thicken evenly and move evenly closer to the center.

Thus, a parasternal image of the LV along its long axis allows the researcher to assess the uniformity of contraction of its walls, the interventricular septum and the posterior wall. At the same time, with this ultrasound slice, in most patients it is not possible to visualize the LV apex and evaluate its contraction.

With this ultrasound section, the coronary sinus is visualized in the atrioventricular groove - a formation smaller in diameter than the descending aorta. The coronary sinus collects venous blood from the myocardium and carries it to the right atrium, and in some patients the coronary sinus is much wider than normal and can be confused with the descending aorta. Enlargement of the coronary sinus in most cases occurs due to the fact that the accessory left superior vena cava flows into it, which is an anomaly in the development of the venous system.

To evaluate the RV outflow tract and determine the movement and condition of the pulmonary valve leaflets, as well as to view the proximal part of the PA and take Doppler measurements of blood flow through the PA valve, it is necessary to remove the PA valve along with the RV outflow tract and the pulmonary trunk. For this purpose, from the parasternal approach, having obtained an image of the LV along the long axis, the sensor must be slightly rotated clockwise and tilted at an acute angle to the chest, directing the scanning line under the left shoulder joint (Fig. 7.8). For better visualization, positioning the patient on the left side with holding the breath as you exhale often helps.

This image makes it possible to evaluate the movement of the pulmonary valve leaflets, which move in the same way as the aortic valve leaflets, and in systole they are completely adjacent to the walls of the artery and are no longer visualized. In diastole they close, preventing the reverse flow of blood into the pancreas. Normal Doppler studies often reveal weak backflow through the pulmonary valve, which is not typical for a normal aortic valve.

Rice. 7.8. Scheme of the outflow tract of the pancreas, parasternal access along the long axis. PZhvyn. tract - outflow tract of the pancreas; KLA - valve PA - outflow tract of the pancreas; KLA - LA valve

To visualize the inflow tract of the pancreas, it is necessary to direct the ultrasound beam from the visualization point of the left ventricle along the long axis to the retrosternal region and slightly rotate the sensor clockwise (Fig. 7.9).

Rice. 7.9. Pancreatic afferent tract (parasternal position, long axis). ZS - posterior leaflet of the tricuspid valve, PS - anterior leaflet of the tricuspid valve

With this scanning plane, the position and movement of the tricuspid valve leaflets is determined quite well, where the anterior leaflet is relatively larger and longer than the posterior or septal leaflet. Normally, the tricuspid valve practically repeats the movements of the mitral valve in diastole.

Without changing the orientation of the sensor, it is often possible to identify the place where the coronary sinus flows into the right atrium.

Parasternal short axis approach

In real time, this image makes it possible to evaluate the movement of the mitral and tricuspid valves.

Normally, during diastole they diverge in opposite directions, and during systole they move towards each other. In this case, attention should be paid to the uniformity of circular contractility of the LV (all its walls should contract, approaching the center at the same distance, while simultaneously thickening), the movement of the interventricular septum; The pancreas, which in this section has a crescent-shaped or close to triangular shape, and its wall contracts in the same direction as the interventricular septum.

To obtain an image of the heart from the parasternal short-axis approach, it is necessary to place the sensor in the third or fourth intercostal space to the left of the edge of the sternum at a right angle to the anterior chest wall, then turn the sensor clockwise until the scanning plane is perpendicular to the long axis of the heart . Next, tilting the sensor towards the apex of the heart, we obtain different sections along the short axis. On the first slice, we obtain a parasternal short-axis image of the LV at the level of the papillary muscles, which look like two round echogenic formations located closer to the LV wall (Fig. 7.10).

From the resulting cross-sectional image of the heart at the level of the papillary muscles, the scanning plane should be tilted towards the base of the heart to obtain a short-axis slice of the LV at the level of the mitral valve (Fig. 7.11). Then, tilting the scanning plane towards the base of the heart, we visualize the ultrasound plane at the level of the aortic valve (Fig. 7.12a).

In this scanning plane, the aortic root and aortic valve leaflets are in the center of the image and normally, when the leaflets are closed, they form a characteristic figure resembling the letter Y. The right coronary leaflet is located superiorly. The non-coronary cusp is adjacent to the right atrium, and the left coronary cusp is adjacent to the left atrium. During systole, the leaflets of the aortic valve open, forming a triangle-shaped figure (Fig. 7.12b). On this section, you can evaluate the movement of the valve flaps and their condition. In this case, the outflow tract of the pancreas is located in front of the aortic ring, and the initial part of the pulmonary trunk is visible for a short distance.

Rice. 7.10. Parasternal approach, short-axis cut at the level of the papillary muscles

Rice. 7.11. Parasternal approach, short axis at the level of the mitral valve

To identify congenital aortic valve abnormalities, such as the bicuspid aortic valve, which is the most common congenital heart defect, this section is optimal.

Often, with the same position of the sensor, it is possible to determine the mouth and main trunk of the left coronary artery, which are visible over a limited scanning distance.

With a greater inclination of the scanning plane to the base of the heart, we obtain a slice at the level of the PA bifurcation, which makes it possible to evaluate the anatomical features of the vessel, the diameter of its branches, and is also used for Doppler measurement of blood flow velocity and determination of its nature. Using color Doppler ultrasound at a given position of the scanning beam, it is possible to detect turbulent blood flow from the descending aorta to the PA at the bifurcation of the PA,

Rice. 7.12. Aortic valve (a - closure; b - opening), parasternal access, short axis, which is one of the diagnostic criteria for patent ductus arteriosus.

If you tilt the sensor to the apex of the heart as much as possible, you can obtain a short-axis slice of it, which makes it possible to evaluate the synchronicity of contraction of all segments of the LV, the cavity of which in this section normally has a rounded shape.

Apical access

The apical approach is used primarily to determine the uniformity of contraction of all walls of the heart, as well as the movement of the mitral and tricuspid valves.

In addition to the structural assessment of the valves and the study of segmental myocardial contractility, apical images create more favorable conditions for Doppler assessment of blood flow. It is with this position of the sensor that the blood flows parallel or almost parallel to the direction of the ultrasound beams, which ensures high accuracy of measurements. Therefore, using the apical approach, Doppler measurements such as determination of blood flow velocities and pressure gradients across the valves are performed.

With the apical approach, visualization of all four chambers of the heart is achieved by placing the transducer at the apex of the heart and tilting the scanning line until the desired image is obtained on the screen (Fig. 7.13).

To achieve the best visualization, the patient should be placed on his left side, and the sensor should be installed in the area of ​​the apical impulse parallel to the ribs and directed to the right scapula.

Currently, the most commonly used orientation of the echoCG image is so that the apex of the heart is at the top of the screen.

For better orientation in visualized echocardiography, it is necessary to take into account that the septal leaflet of the tricuspid valve is attached to the heart wall slightly closer to the apex than the anterior leaflet of the mitral valve. In the cavity of the pancreas, with correct visualization, a moderator cord is detected. Unlike the LV, the trabecular structure is more pronounced in the RV. By continuing the examination, an experienced operator can easily obtain a short-axis image of the descending aorta below the left atrium.

It must be remembered that optimal visualization of any structure during ultrasound is achieved only if this structure is placed perpendicular to the path of the ultrasound beam; if the structure is located parallel, the image will be less clear, and if the thickness is small, even absent. This is why quite often, from the apical approach, with a four-chamber image, the central part of the interatrial septum often appears to be missing. Thus, to identify an atrial septal defect, it is necessary to use other approaches, and take into account that with the apical four-chamber image, the interventricular septum is most clearly visualized in its lower part. Changes in the functional state of a segment of the interventricular septum depend on the state of the blood supplying coronary artery. Thus, deterioration in the function of the basal segments of the interventricular septum depends on the condition of the right or circumflex branches of the left coronary artery, and the apical and middle segments of the septum depend on the anterior descending branch of the left coronary artery. Accordingly, the functional state of the lateral wall of the LV depends on the narrowing or occlusion of the circumflex branch.

Rice. 7.13. Apical four-chamber image

In order to obtain an apical five-chamber image, it is necessary, after obtaining an apical four-chamber image, to tilt the sensor towards the anterior abdominal wall and orient the plane of the echoCG slice under the right clavicle (Fig. 7.14).

With Doppler echocardiography, the apical five-chamber image is used to calculate the main indicators of blood flow in the LV outflow tract.

By defining the four-chamber apical image as the initial transducer position, it is easy to visualize the apical two-chamber image. For this purpose, the sensor is rotated counterclockwise by 90° and tilted laterally (Fig. 7.15).

The LV, which is located at the top, is separated from the atrium by both mitral leaflets. The ventricular wall on the right side of the screen is anterior, and on the left is posterior diaphragmatic.

Rice. 7.14. Five-chamber apical image

Rice. 7.15. Apical position, left two-chamber image

Since the LV walls are quite clearly visible in this position, the left two-chamber image from the apical approach is used to assess the uniformity of LV wall contraction.

With this dynamic image, it is possible to correctly assess the functioning of the mitral and aortic valves.

Using a “cinema loop” in this echoCG position, it is also possible to determine the segmental contractility of the interventricular septum and the posterolateral wall of the LV and, based on this, indirectly assess the blood flow in the circumflex branch of the left coronary artery, as well as partially in the right coronary artery, which participate in the blood supply to the posterolateral wall LV.

Subcostal access

The most common cause of shunt flows and their acoustic equivalents are atrial septal defects. According to various statistics, these defects account for 3–21% of cases of all congenital heart defects. It is known that this is the most frequently developing defect in the adult population.

With a subcostal four-chamber image (Fig. 7.16), the position of the interatrial septum in relation to the course of the rays becomes close to perpendicular. Therefore, it is from this access that the best visualization of the interatrial septum is achieved and its defects are diagnosed.

To visualize all four chambers of the heart from a subcostal approach, the transducer is placed at the xiphoid process, and the scanning plane is oriented vertically and tilted upward so that the angle between the transducer and the abdominal wall is 30–40° (see Figure 7.16). With this section above the heart, the liver parenchyma is also determined. The peculiarity of this ultrasound image is that it is not possible to see the apex of the heart.

A direct echoCG sign of a defect is the loss of a section of the septum, which appears black relative to white on a gray scale image.

In the practice of echocardiography, the greatest difficulties arise in diagnosing a defect of the venous sinus (sinus venosus), especially high defects localized at the superior vena cava.

As is known, there are features of ultrasound diagnostics of a venous sinus defect associated with visualization of the interatrial septum. In order to see this sector of the interatrial septum from the initial position of the sensor (at which subcostal visualization of the four chambers of the heart was obtained), it is necessary to rotate it clockwise with the orientation of the scanning beam plane under the right sternoclavicular junction. The resulting echocardiography clearly shows the transition of the interatrial septum into the wall of the superior vena cava

Rice. 7.16. Subcostal long axis position with visualization of the four chambers of the heart

Rice. 7.17. Place of entry of the superior vena cava into the right atrium (subcostal position)

The next step in the patient's examination is to obtain images of both the four chambers of the heart and the ascending aorta using a subcostal approach (Fig. 7.18). To do this, the sensor scanning line from the starting point is tilted even higher.

It should be noted that this echoCG section is the most correct and often used when examining patients with emphysema, as well as in patients with obesity and narrow intercostal spaces to study the aortic valve.

Rice. 7.18. Subcostal long axis view showing the four chambers of the heart and the ascending aorta

To obtain a short-axis image from the subcostal approach, the transducer should be rotated clockwise 90° based on the imaging position of the subcostal four-chamber image. As a result of the performed manipulations, it is possible to obtain a number of graphic sections at different levels of the heart along the short axis, the most informative of which are sections at the level of the papillary muscles, mitral valve (Fig. 7.19a) and at the level of the base of the heart (Fig. 7.19b).

Next, to visualize the image of the inferior vena cava along its long axis from the subcostal approach, the sensor is placed in the epigastric fossa, and the scanning plane is oriented sagittally along the midline, slightly tilted to the right. In this case, the inferior vena cava is visualized posterior to the liver. On inhalation, the inferior vena cava partially collapses, and on exhalation, when intrathoracic pressure increases, it becomes wider.

Determining the image of the abdominal aorta along its long axis requires the scanning plane to be oriented sagittally, with the sensor placed in the epigastric fossa and tilted slightly to the left. In this position, the characteristic pulsation of the aorta is visible, and in front of it the superior mesenteric artery is clearly visualized, which, having separated from the aorta, immediately turns down and runs parallel to it.

Rice. 7.19. Subcostal position, short axis, section at the level of: a) mitral valve; b) base of the heart

If you rotate the scanning plane by 90°, you can see a cross-section of their vessels along the short axis. On echocardiography, the inferior vena cava is located to the right of the spine and has a shape close to a triangle, while the aorta is located to the left of the spine.

Suprasternal access

The suprasternal approach is used mainly to examine the ascending thoracic aorta and the initial part of its descending aorta.

When placing the sensor in the jugular fossa, the scanning plane is directed downward and oriented along the course of the aortic arch (Fig. 7.20).

Under the horizontal part of the thoracic aorta, a cross-section of the right branch of the pulmonary artery along the short axis is visualized. In this case, it is possible to clearly deduce the origin of the arterial branches from the aortic arch: the brachiocephalic trunk, the left carotid and subclavian arteries.

Rice. 7.20. 2D long axis view of the aortic arch (suprasternal view)

In this position, the entire ascending thoracic aorta, including the aortic valve and part of the LV, is most correctly visualized when the scanning plane is tilted slightly forward and to the right. From this starting point, the scanning plane is rotated clockwise to obtain a transverse (short axis) cross-sectional image of the aortic arch.

On this echocardiography, the horizontal section of the aortic arch looks like a ring, and to the right of it is the superior vena cava. Further, under the aorta, the right branch of the PA is visible along the long axis and even deeper - the left atrium. In some cases, it is possible to see the place where all four pulmonary veins flow into the left atrium. By installing the sensor in the right supraclavicular fossa and directing the scanning plane downward, you can visualize the superior vena cava along its entire length.

Recommendations for conducting echocardiography in patients with cardiac pathology in accordance with the guidelines for the clinical use of echocardiography by the ACC, AHA and the American Society of Echocardiology (ASE) (Cheitlin M.D., 2003) are presented in table. 7.1, 7.3–7.20.

Thus, using different approaches to the heart, it is possible to obtain numerous sections, which make it possible to evaluate the anatomical structure of the heart, the dimensions of its chambers and walls, and the relative position of the vessels.

Table 7.1

*TT echocardiography should be the first choice in these situations, and transesophageal echocardiography should only be used if the study is incomplete or additional information is needed. Transesophageal echocardiography is a technique indicated for examining the aorta, especially in emergency situations.

Classification of the effectiveness and feasibility of using a certain procedure

Class I - the presence of expert consensus and/or evidence of the effectiveness, feasibility of use and beneficial effects of the procedure.

Class II - Controversial evidence and lack of expert consensus regarding the effectiveness and appropriateness of the procedure:

- ІІа - the “scales” of evidence/expert consensus weigh in favor of the effectiveness and expediency of the procedure;

- IIb - the “scales” of evidence/expert consensus tip towards the ineffectiveness and inexpediency of using the procedure.

Class III - the presence of expert consensus and/or evidence regarding the ineffectiveness and inappropriateness of the procedure, and in some cases even its harm.

Unfortunately, it is not always possible to obtain a high-quality image from the various approaches described in this section, especially if the heart is covered by the lungs, the intercostal spaces are narrow, the abdomen has a thick layer of subcutaneous fat, and the neck is short and thick, then echocardiography becomes difficult.

Doppler echocardiography

The essence of the method is based on the Doppler effect and in relation to echocardiography is that the ultrasound beam reflected from a moving object changes its frequency depending on the speed of the object. The peculiarity of the frequency shift of the ultrasound signal depends on the direction of movement of the object: if the object is moving from the sensor, then the frequency of the ultrasound reflected from the object will be lower than the frequency of the ultrasound that was sent by the sensor. And accordingly, if an object moves in the direction of the sensor, then the frequency of the ultrasonic signal in the reflected beam will be higher than the original one.

In this case, by analyzing changes in the frequency of ultrasound reflected from a moving object, the following is determined:

The speed of the object, which is greater, the greater the frequency shift of the sent and reflected ultrasonic signal;

The direction of movement of the object.

The change in the frequency of reflected ultrasound also depends on the angle between the direction of movement of the object and the direction of the scanning ultrasound beam. At the same time, the frequency shift will be greatest when both directions coincide. If the sent ultrasound beam is oriented perpendicular to the direction of movement of the object, the frequency of reflected ultrasound will not change. Thus, for greater accuracy of measurements, it is necessary to strive to direct the ultrasound beam parallel to the line of movement of the object. Naturally, fulfilling this condition can be difficult and sometimes simply impossible. For this reason, modern echocardiographs are equipped with an angular correction program that automatically takes into account the angular correction when calculating the pressure gradient as well as blood flow velocity.

For this purpose, the Doppler equation is used, which allows you to correctly determine the speed of blood flow, taking into account the correction for the angle between the direction of blood flow and the line of emitted ultrasound:

Where V is the speed of blood flow, c is the speed of propagation of ultrasound in the medium (constant value equal to 1560 m/s), Δf is the frequency shift of the ultrasound signal, f 0 is the initial frequency of the emitted ultrasound, Θ is the angle between the direction of blood flow and the direction of the emitted ultrasound.

When determining the speed of blood flow in the heart and vessels, the role of the moving object is erythrocytes, which move both relative to the ultrasound beam of the sensor and relative to the reflected signal. That is why, as can be seen from the equation, the coefficient in the numerator is equal to 2, since the frequency shift of the ultrasonic signal occurs twice.

Thus, the frequency shift also depends on the frequency of the sent signal: the lower it is, the higher the speeds can be measured, which depends on the sensor, the frequency of which must be selected the lowest.

Currently, there are several types of Doppler studies, namely: Pulsed wave Doppler, Continuous wave Doppler, Doppler Tissue Imaging, Power Doppler (Color Doppler Energy), color Doppler echocardiography (Color Doppler).

Pulsed wave Doppler echocardiography

The essence of the pulsed wave Doppler echocardiography method is that the sensor uses only one piezoelectric crystal, which serves simultaneously to generate an ultrasound wave and to receive reflected signals. In this case, the radiation comes in the form of a series of pulses, the next one is emitted after recording the reflected previous ultrasonic oscillations. The sent ultrasonic pulses, partially reflected from the object whose movement speed is measured, change the oscillation frequency and are recorded by the sensor. Taking into account the known speed of propagation of a sound wave in the medium (1540 m/s), the device has the software ability to selectively analyze only waves reflected from objects located at a certain distance from the sensor in the so-called control or trial volume. Using pulsed wave Doppler echocardiography at great depths, it is possible to correctly determine only blood flow, the speed of which does not exceed 2 m/s. At the same time, at shallower depths it is possible to carry out fairly accurate measurements of higher-speed blood flows.

Thus, the advantage of the pulsed wave Doppler echocardiography method is that it provides the ability to determine the speed, direction and nature of blood flow in a specific zone of a specified volume.

There is a direct relationship between the repetition rate of ultrasound signals and the maximum blood flow rate. The maximum blood flow velocity measured by this method is limited by the Nyquist limit. This is due to the occurrence of Doppler spectrum distortion when calculating velocities that exceed the Nyquist limit. In this case, only part of the Doppler spectrum curve on the opposite side of the zero velocity line is visualized, and the other part of the spectrum is leveled at the speed level corresponding to the Nyquist limit.

In this regard, to ensure the correctness of the measurements, the repetition rate of emitted pulses is reduced when studying blood flows in the surveyed area, located far from the sensor. To avoid distortion of measurements on the spectral Doppler curve, when performing a pulsed wave Doppler study, the value of the maximum blood flow velocity that can be determined is reduced. On the screen, the echoCG graph of the Doppler spectrum is presented as a velocity sweep over time. In this case, the graph above the isoline shows the blood flow directed to the sensor, and below the isoline - from the sensor. Thus, the graph itself consists of a set of points, the brightness of which is directly proportional to the number of red blood cells moving at a certain speed at a given time. The image of the graph of the Doppler velocity spectrum during laminar blood flow is characterized by a small width due to a small spread of velocities, and is a relatively narrow line consisting of points with approximately the same brightness.

Unlike the laminar type of blood flow, the turbulent type is characterized by a greater spread of speeds and an increase in the width of the visible spectrum, since it occurs in places where the blood flow accelerates when the lumen of the vessels narrows. In this case, the Doppler spectrum graph consists of many points of different brightness, located at different distances from the baseline velocity, and is visualized on the screen as a wide line with blurred contours.

It should be noted that for the correct orientation of the ultrasound beam when performing a Doppler study, echoCG devices have a sound mode provided by the method of transforming Doppler frequencies into ordinary sound signals. To assess the speed and nature of blood flow through the mitral and tricuspid valves using pulsed wave Doppler echocardiography, the sensor is oriented to obtain an apical image with the control volume placed at the level of the valve leaflets with a slight displacement towards the apex from the annulus fibrosus (Fig. 7.21).

Rice. 7.21. Pulsed wave Doppler echocardiography (mitral blood flow)

The study of blood flow through the mitral valve with pulsed wave Doppler echocardiography is carried out using not only four-chamber, but also two-chamber apical images. By placing the control volume at the level of the mitral valve leaflets, the maximum speed of transmitral blood flow is determined. Normally, diastolic mitral blood flow is laminar, and the spectrum of the mitral blood flow curve is located above the baseline and has two velocity peaks. The first peak is normally higher and corresponds to the phase of rapid filling of the LV, and the second peak velocity is less than the first and is a reflection of blood flow during contraction of the left atrium. The maximum speed of transmitral blood flow is normally in the range of 0.9-1.0 m/s. When studying blood flow in the aorta at the apical position of the sensor, on a normal graph of blood flow velocity, the spectrum of the aortic blood flow curve is below the isoline, since the blood flow is directed away from the sensor. The maximum speed is noted at the level of the aortic valve, because this is the narrowest place.

If, during a Doppler pulse wave study, high-velocity blood flow is detected during mitral regurgitation, then a correct determination of the blood flow velocity becomes impossible due to the Nyquist limit. In these cases, continuous-wave Doppler echocardiography is used to accurately determine high-velocity flows.

Continuous wave Doppler echocardiography

In continuous wave Doppler, one or more piezoelectric elements continuously emit ultrasound waves, and other piezoelectric elements continuously receive reflected ultrasound signals. The main advantage of the method is the ability to study high-speed blood flow throughout the entire depth of study along the path of the scanning beam without distorting the Doppler spectrum. However, the disadvantage of this Doppler study is the impossibility of spatial localization in depth of the site of blood flow.

For continuous wave Doppler echocardiography, two types of sensors are used. The use of one of them makes it possible to simultaneously visualize a two-dimensional image in real time and examine blood flow by directing the ultrasound beam to the site of diagnostic interest. Unfortunately, due to their rather large size, these sensors are inconvenient to use in patients with narrow intercostal spaces and it is difficult to orient the ultrasound beam as parallel to the blood flow as possible. When using a sensor with a small surface, it becomes possible to achieve good quality constant wave Doppler studies, but without obtaining a two-dimensional image, which can create difficulties for the researcher when orienting the scanning beam.

To ensure accurate targeting of the ultrasound beam, it is necessary to memorize the location of the 2D transducer before switching to a finger-type transducer. It is also important to know the distinctive features of flow graphics for various pathologies. In particular, the flow of tricuspid regurgitation, in contrast to mitral regurgitation, accelerates during inspiration and has a longer pressure half-time. At the same time, you should not forget to use different accesses. Study of blood flow during aortic stenosis performed both with apical and suprasternal access.

The obtained information is provided in acoustic and graphic form, which displays the flow velocity over time.

In Fig. Figure 7.22 shows the apical image of the LV along the long axis, where the direction of the ultrasound wave into the lumen of the aortic valve is displayed as a solid line. The blood flow velocity graph is a curve with a completely filled lumen under the frame and displays all velocities determined along the course of the ultrasound beam. The maximum speed is recorded along the sharp edge of the parabola and reflects the speed of blood flow in the opening of the aortic valve. During normal blood flow, the spectrum of the waveform is below the baseline because the flow of blood through the aortic valve is directed away from the sensor.

Rice. 7.22. Measuring aortic flow with continuous wave Doppler echocardiography

It is known that the greater the pressure difference above and below the site of narrowing, the greater the speed in the area of ​​stenosis, and vice versa; From this, the pressure gradient can be determined. This pattern is used to calculate the pressure gradient based on the speed of blood flow at the site of stenosis. These calculations are made using the Bernoulli formula:

ΔР = 4 V 2,

Where ΔР - pressure gradient (m/s), V - maximum flow velocity (m/s).

Thus, by determining the maximum velocity and calculating the maximum systolic pressure gradient between the ventricle and the corresponding vessel, the severity of aortic and pulmonary valve stenosis can be assessed.

In the case of determining the severity of mitral stenosis, the average diastolic pressure gradient across the mitral valve is used.

This gradient is calculated from the average velocity of diastolic blood flow through the mitral orifice. Modern echocardiographs are equipped with programs for automatically calculating the average speed of diastolic blood flow and pressure gradient. To do this, you simply need to trace the spectrum of the transmitral blood flow curve.

For patients with a ventricular septal defect, the gradient value systolic pressure between the LV and RV has great prognostic significance. When calculating this systolic pressure gradient, the speed of blood flow through the defect from one chamber of the heart to another is determined. For this purpose, a constant wave Doppler study is carried out with the sensor oriented in such a way that the ultrasound beam passes through the defect as parallel to the blood flow as possible.

Thus, continuous wave Doppler echocardiography is effectively used to determine high instantaneous blood flow velocities. In addition, the method is widely used to determine the values ​​of the velocity/time integral, as well as the maximum blood flow velocity, calculate the pressure gradient and the time for the pressure gradient to halve. Using a constant wave Doppler study, the pressure gradient in the PA is measured, the dp/dt parameter of both ventricles of the heart is calculated, and the dynamic pressure gradient is measured during obstruction of the LV outflow tract.

Color Doppler echocardiography

The color Doppler echocardiography method makes it possible to automatically determine the nature and speed of blood flow simultaneously in a large number of points within a given sector, and the information is provided in the form of color, which is superimposed on the main two-dimensional image. Each point is coded with a specific color depending on the direction and speed of red blood cells moving in it. When the dots are placed tightly enough and evaluated in real time, an image can be obtained that is perceived as the movement of colored streams through the heart and blood vessels.

The principle of color Doppler mapping is essentially no different from pulsed wave Doppler echocardiography. The only difference is in the mode of presentation of the received information. In pulsed wave Doppler, a control volume is moved across a two-dimensional image in areas of interest to determine blood flow, and the information obtained is displayed as a graph of blood flow velocities. Different shades of red and blue usually indicate the direction of blood flow, as well as the average speed and the presence of Doppler spectrum distortion.

The direction of flow in one direction may be in the red-yellow color spectrum, and in the other in the blue-cyan color spectrum. Only two main directions are taken into account: towards the sensor and away from the sensor. Typically, blood flows directed towards the sensor appear in red on echocardiography, and those directed away from the sensor appear in blue (Fig. 7.23).

The speed of blood flow is differentiated by the brightness of the color spectrum in the resulting image. The brighter the color, the higher the flow rate. If the velocity is zero and there is no blood flow, the screen displays black.

Rice. 7.23. Color Doppler echocardiography, apical access: a) diastole; b) systole

All modern echocardiographs display a color scale on the screen, displaying the correspondence of the direction and speed of blood flow to a particular color spectrum.

With turbulent flows, shades of green are usually added to the primary colors - red and blue - which manifests itself as a mosaic of color during color mapping. Such shades appear when recording regurgitation or flows of stenotic lumens. Like any method, color Doppler echocardiography has its drawbacks, the main of which are the relatively low temporal resolution, as well as the inability to display high-speed blood flows without distortion. The last drawback is related to the overshoot phenomenon, which occurs when the detected blood flow velocity exceeds the Nyquist limit and is visualized on the screen through white color. It should be noted that when using the color mapping mode, the quality of the 2D image often deteriorates.

When studying different parts of the aorta, it is possible to visualize a change in the direction of flows in relation to the scanning beam of the sensor. In relation to the ultrasound beam in the ascending aorta, the blood flow goes in the opposite direction and is displayed in shades of red. In the descending aorta, the opposite direction of blood flow is noted (from the scanning beam), which is accordingly visualized in shades of blue. If the blood flow has a direction perpendicular to the ultrasound beam, then the velocity vector when projected onto the scanning direction gives a zero value. This area appears as a black stripe separating red and blue, indicating zero speed. Thus, for correct perception of the displayed color gamut, it is necessary to clearly understand the direction of the flows relative to the scanning ultrasonic beam.

Tissue Doppler

The essence of the method is to study myocardial movement using modified Doppler signal processing. The object of study is the moving walls of the myocardium, which provide a color-coded image depending on the direction of their movement, similar to Doppler flow study. The movement of the studied heart structures from the sensor is displayed in shades of blue, and towards the sensor - in shades of red. Myocardial imaging using Doppler echoCG in clinical practice can be used to assess myocardial function, analyze disturbances in regional myocardial contractility (due to the possibility of simultaneous recording of the average velocity of movement of all LV walls), quantitative assessment of systolic and diastolic motion of the myocardium, and visualization of other moving tissue structures of the heart.

Power Doppler study Using the original technique for power Doppler study, it is possible to estimate the flow intensity by analyzing the reflected ultrasound signal from moving red blood cells. The information is displayed in color, as if superimposed on a black-and-white two-dimensional image of the examined organ, defining the vascular bed. This method of Doppler research has actively entered clinical medicine and is quite widely used in assessing the blood supply to organs and the degree of their perfusion. The diagnostic capabilities of this method were demonstrated in the study of the vascular bed in case of thrombosis of the deep veins of the leg and the inferior vena cava, differentiation of occlusion of the internal carotid artery from stenosis with weak blood flow, identification of the course of the vertebral arteries, imaging of vessels with pronounced tortuosity, contouring of plaques narrowing the lumen of blood vessels, as well as transcranial image of cerebral vessels.

M color mode

With the color M-mode technique, an image corresponding to the standard M-mode is visualized on the echocardiograph screen, displaying the speed and direction of blood flow, as with color Doppler echocardiography. The color representation of blood flows has found its use in assessing diastolic relaxation of the myocardium, as well as to determine the localization and duration of turbulent flows.

Transesophageal echocardiography

Transesophageal echocardiography - echocardiography and Doppler echocardiography examination of the heart using an endoscopic probe with a built-in ultrasound sensor.

The esophagus is directly adjacent to the left atrium, which is located anterior to it, and the descending aorta is posterior. As a result, the distance from the aperture of the transesophageal sensor to the cardiac structures is several centimeters or less, while the TT sensor can reach many centimeters. This is one of the determining factors for obtaining a high-quality image. According to the ACC/AHA task force, in more than half of cases, transesophageal echocardiography provides new or additional information about the structure and function of the heart, and clarifies prognosis and treatment tactics. It also presents immediate results in real time on the effectiveness of reconstructive operations and valve replacement immediately after cessation of artificial circulation. The image obtained through the esophagus allows one to overcome the limitations typical of standard TT echocardiography associated with extracardiac factors: 1) respiratory artifacts - COPD (including emphysema), hyperventilation; 2) obesity, the presence of a pronounced layer of subcutaneous fat; 3) pronounced rib cage of the chest; 4) developed mammary glands; as well as with cardiac factors: 1) acoustic shadow of a prosthetic heart valve; 2) valve calcification; 3) small size of space-occupying formations. The method provides an almost absolute, uniform acoustic window of good quality. The use of high-frequency sensors (5–7 MHz) makes it possible to improve spatial resolution in the axial and lateral directions by an order of magnitude. This is another determining factor in obtaining high-quality images that are not available with standard echocardiography. Using this method, it is possible to examine structures that are inaccessible with standard echoCG: the superior vena cava, atrial appendages, pulmonary veins, proximal parts of the coronary arteries, sinuses of Valsalva, thoracic aorta.

New opportunities have been opened in the study of the right heart. The unique capabilities of transesophageal echocardiography have been identified in patients in critical condition, with intraoperative monitoring of ventricular function, when diagnosis of hypovolemia, ventricular systolic dysfunction, transient ischemia, and MI is required. The method is highly effective for the differential diagnosis of volumetric and conventionally accepted as volumetric formations of the heart: tumors, blood clots; precursors of systemic thromboembolism: spontaneous echocardiographic contrast of the cavity, fibin filaments; small vegetations, prosthetic valve suture threads, false chords of the ventricle, myxomatous degeneration of the mitral valve. The transesophageal echocardiography method was compared with other methods, including those considered as standard, including standard two-dimensional echocardiography (Kovalenko V.N. et al., 2003).

The study protocol is determined by the specific clinical situation; transesophageal echocardiography is always preceded by transthoracic echocardiography.

Indications for transesophageal echocardiography

1. Suboptimal standard TT echocardiography.

2. Identification of the infarct-causing coronary artery.

3. Assessment of the effectiveness of reconstructive operations, valve replacement, transplanted heart, the viability of aortocoronary mammary-coronary bypass grafts immediately after exit from artificial circulation. Evaluation of coronary artery stenting.

4. Intraoperative monitoring of general and local ventricular function; diagnosis of ischemia, MI; differentiation of hypovolemia/ventricular systolic dysfunction.

5. Accurate diagnosis of the significance of stenotic and regurgitant flows in heart defects.

6. Pathological conditions of the aorta, including dissecting aneurysm, coarctation.

7. The need for a differential diagnosis of space-occupying and conditionally accepted as space-occupying cardiac formations:

7.1. Tumor.

7.2. Thrombus.

7.3. Vegetation ( infective endocarditis).

7.4. Valve ring abscess.

7.5. Aneurysmal dilatation of the coronary artery.

7.6. Aneurysm of the atrial septum, its lipomatosis.

7.7. Myxomatous degeneration of the mitral valve sails.

7.8. False chord of the ventricle.

7.9. Hiari Network.

7.10. Prosthetic valve suture threads.

7.11. Spontaneous echocardiography contrasting of the atrium cavity (a harbinger of thromboembolism).

7.12. Fibrin threads (a harbinger of thromboembolism).

7.13. Microbubbles.

8. Assessment of infectious complications associated with installed catheters and electrodes, including the pacemaker electrode.

9. Diagnosis of septal defects, including small communications.

10. Presence of recurrent RV rhythms (suspicion of arrhythmogenic dysplasia of the RV heart).

11. The suspected source of systemic thromboembolism is in the atria or atrial appendage, the inferior vena cava.

12. Detection of paradoxical air embolism in patients during neurosurgical procedures, laparoscopy, cervical laminectomy.

13. TELA.

14. Monitoring the effectiveness of pericardiocentesis and endomyocardial biopsy.

15. Selection of donors for heart transplantation.

Complications of the transesophageal echocardiography procedure

Heavy

1. Perforation of the esophagus.

3. Trauma to the oral cavity.

4. Bleeding from varicose veins of the esophagus or due to fragmentation of an intraesophageal tumor.

5. Ventricular fibrillation, other ventricular rhythms.

6. Laryngospasm.

7. Bronchospasm.

8. Tonic, clonic convulsions.

9. Myocardial ischemia.

Lungs

1. Transient hypo- and hypertension.

2. Vomiting.

3. Supraventricular rhythm disturbances.

4. Angina.

5. Hypoxemia.

Main scanning planes

The transesophageal echocardiography technique involves a study plan that is divided into three stages. Basal, four-chamber and transgastric scanning are possible at various points of localization of the endoscope tip relative to the distance from the patient’s anterior teeth (Fig. 7.24).

Then they move from the general research plan to the specific one, obtaining standard resulting scanning planes. By scanning along the basal short axis, at least four standard views are obtained: 1 to 4 (see Fig. 7.24). In the four-chamber section there are three views: from 5 to 7, which approximately corresponds to standard TT two-dimensional echoCG views along the long axis. When the end of the endoscope is placed in the fundus of the stomach (short-axis transgastric scanning), a cross-section of the ventricles is obtained at the level of the middle sections of the papillary muscles of the LV (see Fig. 7.24, view 8), where the local function of the segments of the ventricular walls is analyzed and its overall function is monitored.

The signal amplification level is initially set before artifacts are obtained - that is, high in order to determine the true contours of the endocardium.

By tilting the end of the endoscope upward or slightly withdrawing it, a sequential scanning of the structures along the basal short axis is obtained (see Fig. 7.24, view 1).

This places the tip of the endoscope just posterior to the left atrium.

Rice. 7.24. Diagram of transition from primary scanning planes

V.N. Kovalenko, S.I. Deyak, T.V. Getman "Echocardiography in cardiology"

By placing an ultrasound probe on the chest, countless two-dimensional images (sections) of the heart can be obtained. From all possible sections, several are distinguished, which are called “standard positions”. The ability to obtain all the necessary standard positions and analyze them forms the basis of knowledge of echocardiography.

The names of standard positions include the position of the sensor relative to the chest, the spatial orientation of the scanning plane, and the names of the visualized structures. Strictly speaking, it is the position of the heart structures on the screen that determines one or another standard position. For example, the position of the transducer when obtaining a parasternal short axis of the left ventricle at the level of the mitral valve can vary greatly between patients; the criterion that the position is obtained correctly will be the detection of the right and left ventricles, the interventricular septum and the mitral valve in the correct relationship. In other words, standard echocardiographic positions are not standard ultrasound transducer positions, but standard images of cardiac structures.

In table 3 we provide a list of the main standard echocardiographic positions of the heart and the anatomical landmarks necessary to obtain them correctly.

Table 3. Standard echocardiographic positions
Position	Main anatomical landmarks
Parasternal access
LV long axis*	a) Maximum opening of the mitral valve, aortic valve b) Maximum opening of the aortic valve, mitral valve
Long axis of the pancreatic afferent tract*	Maximum opening of the tricuspid valve, absence of structures of the left chambers of the heart
Short axis of the aortic valve*	Tricuspid, aortic valves, round section of the aortic root
LV short axis at the level of the mitral valve*	Mitral valve, interventricular septum
LV short axis at the level of the papillary muscles*	Papillary muscles, interventricular septum
Apical access
Four-chamber position*	LV apex, interventricular septum, mitral, tricuspid valves
“Five-chamber position”*	LV apex, interventricular septum, mitral, tricuspid, aortic valves
Dual chamber position*	LV apex, mitral valve, absence of right heart structures
Long axis of the left ventricle**	LV apex, interventricular septum, mitral, aortic valves
Subcostal access
Long axis of the heart**	Interatrial, interventricular septum, mitral, tricuspid valves
Short axis of the base of the heart**	Pulmonary valve, tricuspid, aortic valves
Long axis of the abdominal aorta**	Longitudinal section of the abdominal aorta passing through its diameter
Long axis of the inferior vena cava*	Longitudinal section of the inferior vena cava passing through its diameter
Suprasternal access
Long axis of the aortic arch**	Aortic arch, right pulmonary artery
LV - left ventricle, RV - right ventricle * Positions for which registration is required for all patients. **Additional items.

Parasternal access

Parasternal position of the long axis of the left ventricle (Fig. 2.1A,B)

This is the position from which the echocardiographic examination begins. It is intended mainly to study the structures of the left chambers of the heart. In addition, under the control of a two-dimensional image of the heart in the position of the parasternal long axis of the left ventricle, b O most of the M-modal study.

IN.

Figure 2.1. Parasternal position of the long axis of the left ventricle with optimal visualization of the mitral valve ( A) and aortic valve ( IN). LV - left ventricle, RV - right ventricle, Ao - aortic root and ascending aorta, LA - left atrium, IVS - interventricular septum, PW - posterior wall of the left ventricle, dAo - descending aorta, CS - coronary sinus, RCC - right coronary cusp of the aortic valve, NCC - non-coronary cusp of the aortic valve, aML - anterior cusp of the aortic valve, NCC - non-coronary cusp of the aortic valve, aML - anterior cusp of the mitral valve, pML - posterior cusp of the mitral valve.

The sensor is installed to the left of the sternum in the third, fourth or fifth intercostal space. The central ultrasound beam (an extension of the long axis of the sensor) is directed perpendicular to the surface of the chest. The sensor is rotated so that its plane is parallel to an imaginary line connecting the left shoulder to the right iliac region. To obtain optimal long-axis imaging of the left ventricle, a transducer plane deflection of approximately 30° is often required (the central beam is directed toward the left shoulder). This position dissects the left ventricle from apex to base. The aorta should be on the right side of the image, the area of ​​the apex of the left ventricle should be on the left.

The anterior wall of the right ventricle is closest to the sensor, followed by part of the outflow tract of the right ventricle. Below and to the right are the aortic root and aortic valve. The anterior wall of the aorta passes into the membranous part of the interventricular septum, the posterior wall of the aorta into the anterior leaflet of the mitral valve. Posterior to the aortic root and ascending aorta is the left atrium. The posterior wall of the left atrium is normally the heart structure farthest from the sensor at a given position. An oval-shaped echo-negative space is often found posterior to the left atrium. This is the descending aorta; Its oval shape is due to the fact that the cut passes at an acute angle to both its long and short axis. The posterior wall of the left atrium passes into the atrioventricular tubercle and then into the posterior wall of the left ventricle. In the area of ​​the atrioventricular tubercle, an echo-negative structure of a round shape is often visible; this is the coronary sinus. When the coronary sinus dilates, it can be mistaken for the descending aorta. However, it is not difficult to distinguish these structures: the coronary sinus moves together with the mitral annulus, but the descending aorta, being an extracardiac structure, does not move with the heart. The posterior wall of the left ventricle is visualized from the level of the mitral annulus to the papillary muscles; By directing the central ultrasound beam downwards, the area of ​​visualization of the posterior wall of the left ventricle can be expanded. The apex of the left ventricle is located one or more intercostal spaces below the transducer installed parasternally and is not included in the slice, so one should not try to judge the local contractility of the apical segments of the left ventricle from this position. Anterior to the posterior wall of the left ventricle is the left ventricular cavity, normally the largest of all structures in this echocardiographic position. The anterior and posterior leaflets of the mitral valve are visualized in the cavity of the left ventricle. The interventricular septum, which limits the cavity of the left ventricle in front, is visible from the membranous part to the area adjacent to the apex of the left ventricle.

The structures of greatest interest in this position - the interventricular septum, aortic and mitral valves - usually cannot be seen perfectly in a single image. Therefore, optimization of images of individual structures is required. The long axis of the ascending aorta is typically at an angle of 30° to the long axis of the left ventricle, so the transducer should be rotated slightly for optimal visualization of the ascending aorta, aortic root, and aortic valve. In Fig. 2.1B shows the parasternal long axis position of the left ventricle, optimized for best visualization of the aortic valve. The sensor plane is rotated so that the diameter of the aortic root and its ascending section is maximum. This allows you to examine the size of the aorta and the maximum opening of the aortic valve leaflets.

For optimal visualization of the mitral valve, the transducer plane is deflected back and forth until a position is obtained in which the mitral valve leaflets open to their maximum (Fig. 2.1A). The sectional plane of the left ventricle should pass between the papillary muscles, so that neither they nor the chordae are included in the image. This position corresponds to the maximum anteroposterior dimension of the left ventricle at the level of its base.

An essential part of the echocardiographic examination is the M-modal examination, which is almost always performed exclusively from the parasternal long axis of the left ventricle. In Fig. 2.2, 2.3, 2.4 show images of standard positions of M-modal research. The two-dimensional image helps to correctly orient the ultrasound beam for M-modal examination.

Figure 2.2. M-modal examination of the aortic valve and left atrium. The left coronary cusp of the aortic valve is not visible, but the right coronary and non-coronary cusps form a “box” during systole. To correctly measure the anteroposterior size of the left atrium, the ultrasound beam must pass perpendicular to its posterior wall. RV - right ventricle, Ao - aortic valve and aortic root, LA - left atrium, R - right coronary cusp of the aortic valve, N - non-coronary cusp of the aortic valve.

Figure 2.3. M-modal study of the right ventricle, left ventricular cavity, mitral valve. The movement of the anterior leaflet of the mitral valve reflects all phases of diastolic filling of the left ventricle: maximum opening of the valve in early diastole, partial closure in the diastasis phase, and later opening of a smaller amplitude in the atrial systole phase. The movement of the posterior leaflet of the mitral valve mirrors the movement of the anterior leaflet. LV - left ventricle, RV - right ventricle, IVS - interventricular septum, PW - posterior wall of the left ventricle, aML - anterior mitral valve leaflet, pML - posterior mitral valve leaflet.

Figure 2.4. M-modal examination of the left ventricular cavity. To correctly measure the size of the cavity and the thickness of the posterior wall of the left ventricle and the thickness of the interventricular septum, it is necessary that the ultrasound beam passes parallel to the short axis of the left ventricle. LV - left ventricle, RV - right ventricle, IVS - interventricular septum, PW - posterior wall of the left ventricle.

Parasternal position of the long axis of the afferent tract of the right ventricle (Fig. 2.5)

This position is intended to examine the right side of the heart, mainly the tricuspid valve. The sensor is installed to the left of the sternum in the third or fourth intercostal space. It should be moved as far away from the sternum as the lungs allow. The central ultrasound beam is directed sharply to the right into the retrosternal region, where the tricuspid valve is located.

Figure 2.5. Parasternal position of the long axis of the afferent tract of the right ventricle. RV - right ventricle, RA - right atrium, TV - tricuspid valve, EV - Eustachian valve.

The sensor plane is rotated 15-30° clockwise from the position of the parasternal long axis of the left ventricle.

The tricuspid valve is in the center of the image. Above and to the left of it is the proximal part of the afferent tract of the right ventricle. At the bottom of the image is the right atrium. The Eustachian valve is often visualized, located in the right atrium at the junction of the inferior vena cava.

In this position, structures related to the left parts of the heart should not be included in the image. The position of the parasternal long axis of the afferent tract of the right ventricle is obtained correctly if the tricuspid valve is in its center, its anterior and posterior leaflets are clearly visible and the diameter of the afferent tract of the right ventricle is maximum.

Parasternal position of the short axis of the aortic valve (Fig. 2.6)

To obtain this position, the sensor is installed in the third or fourth intercostal space to the left of the sternum. The central ultrasound beam is directed perpendicular to the surface of the chest or deviated slightly to the right and upward. The transducer should be rotated 90° relative to the plane in which the parasternal long axis of the left ventricle is recorded. At the top of the image is the outflow tract of the right ventricle, to the right and below it are the pulmonary valve and the trunk of the pulmonary artery. In the center of the image is the aortic valve with three leaflets (left coronary - on the right, right coronary - top left, non-coronary - bottom left). The position of the transducer should be optimized to obtain a clear image of the aortic valve leaflets. The aortic root should have a strictly rounded shape. Minor changes in transducer position often allow visualization of the left main coronary artery and sometimes the right coronary artery (Fig. 2.7).

Figure 2.6. Parasternal position of the short axis of the aortic valve. RVOT - right ventricular outflow tract, LA - left atrium, RA - right atrium, IAS - interatrial septum, L - left coronary cusp of the aortic valve, R - right coronary cusp of the aortic valve, N - non-coronary cusp of the aortic valve, LCA - left coronary valve trunk arteries, TV - tricuspid valve, PV - pulmonary valve.

Figure 2.7. Parasternal position of the short axis of the aortic valve. The scanning plane passes through the proximal ascending aorta and the proximal parts of both coronary arteries. Ao - proximal ascending aorta, LCA - trunk of the left coronary artery, RCA - right coronary artery.

Minor changes in transducer position allow visualization of the infundibular part of the right ventricle, located above the aortic root, the pulmonary valve and the proximal part of the pulmonary artery trunk. Additionally, by turning the sensor clockwise, you can visualize the entire trunk of the pulmonary artery until it bifurcates into the right and left pulmonary arteries (Fig. 2.8). This position is optimal for Doppler examination of blood flow in the pulmonary artery.

Figure 2.8. Parasternal short axis position of the aortic valve, oriented for optimal visualization of the pulmonary artery. This position is sometimes called the parasternal long axis pulmonary artery position. Ao - aortic root, dAo - descending aorta, RVOT - right ventricular outflow tract, PA - trunk pulmonary artery, PV - pulmonary valve, LPA - left pulmonary artery, RPA - right pulmonary artery.

Parasternal position of the short axis of the left ventricle at the level of the mitral valve (Fig. 2.9)

From the many sections of the left ventricle that can be obtained along its parasternal short axis, positions of the parasternal short axis of the left ventricle are distinguished at the level of the mitral valve and at the level of the papillary muscles. These positions are intended for examination of the left ventricle; the right ventricle may occupy a relatively large area on the images only when it is dilated. Sometimes another parasternal position is identified - along the short axis of the left ventricle at the level of the apex, but in practice it is rarely used.

Figure 2.9. Parasternal position of the short axis of the left ventricle at the level of the mitral valve. LV - left ventricle, RV - right ventricle.

To obtain a parasternal short axis of the left ventricle at the level of the mitral valve, the sensor is installed to the left of the sternum in the third, fourth or fifth intercostal space. The central ultrasound beam is directed perpendicular to the surface of the chest or slightly deflected to the left. The transducer should be rotated 90° relative to the plane in which the parasternal long axis of the left ventricle is recorded.

The part of the right ventricle is closest to the sensor, i.e. in the upper part of the image. Structures related to the tricuspid valve are often visible on the left side of the image. Normally, the interventricular septum with its convexity faces the right ventricle. The left ventricle, which occupies b O most of the image, located to the right and below and has a rounded shape. It can be difficult to examine the border of the left ventricular endocardium in the area of ​​its anteromedial and anterolateral walls. The mitral valve is visible in the center of the left ventricle. The position of the parasternal short axis of the left ventricle at the level of the mitral valve is obtained correctly if the left ventricular cavity has a round shape and the anterior (above in the image) and posterior (lower in the image) cusps of the mitral valve are clearly visible.

Parasternal position of the short axis of the left ventricle at the level of the papillary muscles (Fig. 2.10)

To record this position, the sensor is installed in the same position as to obtain the position of the parasternal short axis of the left ventricle at the level of the mitral valve, but the central beam is deflected slightly downward, or the sensor itself is shifted one intercostal space lower.

Figure 2.10. Parasternal position of the short axis of the left ventricle at the level of the papillary muscles. RV - right ventricle, LV - left ventricle, AL - anterolateral papillary muscle, PM - posteromedial papillary muscle.

The right ventricle is even more lateral (to the left in the image) and occupies even less space than in the short axis position of the left ventricle at the level of the mitral valve. The papillary muscles are located at the level of the posteroseptal (posteromedial papillary muscle) and posterolateral (anterolateral papillary muscle) walls of the left ventricle. Thus, the posteromedial papillary muscle is located to the left of the anterolateral muscle in the image. The position of the parasternal short axis of the left ventricle at the level of the papillary muscles is obtained correctly if the left ventricular cavity in the image has a round shape and both papillary muscles are clearly visible.

Lecture for doctors "Basic measurements and calculations in echocardiography." A lecture for doctors is given by Rybakova M.K.

The lecture covers the following issues:

• Standard measurement standards (parasternal position)
• Approach to assessing LV function
  • Assessment of systolic function
  • Diastolic function assessment
  • Assessment of the degree of MR
  • Assessment of local contractility of the LV myocardium
  • Left atrial pressure assessment
  • Assessment of LV EDD
• Principles for assessing ventricular systolic function
  • Estimation of root excursion AO (M*mode)
  • Assessment of the excursion of the left and right fibrous ring (M - mode)
  • Calculation of PV - M - mode
  • Calculation of PV - V - mode
  • Assessment of blood flow in LVOT and RVOT, calculation of LV and RV SV (flow continuity equation)
  • Calculation of the Doppler index of the LV and RV
  • Calculation of the rate of increase in pressure in the LV and RV at the beginning of systole
  • Sm wave rating (PW TDI)
  • Calculation of LV and RV WMSI
• Calculation of stroke volume (SV ml) of the LV and RV using the flow continuity equation
  • SV = integral of linear flow velocity in the outflow tract of the LV or RV X cross-sectional area of ​​the outflow tract
  • LV and RV volume 70 - 100 ml
• Indirect assessment of ventricular systolic function by blood flow velocity in the outflow tract
  • Assessment of blood flow in LVOT and calculation of stroke volume - normal flow speed is 0.8 - 1.75 m/sec
  • Blood flow assessment in RVOT (normal): V RVOT = 0.6 - 0.9 m/sec
• Assessment of pressure in the right side of the heart (basic calculations)
• Methods for assessing pressure in the right ventricle and pulmonary artery
  • Calculation of average pressure in the aircraft according to AT to ET
  • Calculation of average pressure in an aircraft using the Kitabatake equation
  • Calculation of the average pressure in the PA based on the initial diastolic pressure gradient of the pulmonary regurgitation flow
  • Calculation of maximum systolic pressure in the LA using TR
  • Calculation of PA EDP using the end-diastolic pressure gradient of the LA flow
• PV blood flow against the background of LH - color M - modal Doppler

• Calculation of the maximum systolic pressure about the ventricle and pulmonary artery according to the TR flow, CW mode (P max Syst. PA = PG tk syst. + P nn)
• Assessment of prosthetic valve function
  
• Assessment of LV systolic function and local contractility using 3D technology
• Doppler index calculation
  • CI = IVRT + IVCT / ET
  • LV CI = 0.32 +/- 0.02
  • RV CI = 0.28 +/- 0.02
• Assessment of systolic function of excursion of fibrous rings M - mode
• Calculation of the rate of pressure rise in the LV or RV at the beginning of systole (dP/dT)
  • For LV dP/dT more than 1200 mm Hg/sec
  • For the pancreas dP/dT more than 650 mm Hg. Art./sec
• Five-point assessment of local contractility
  • 1 - normokinesis
  • 2 - slight hypokinesis
  • 3- moderate or significant hypokinesis
  • 4 - akinesis
  • 5 - dyskinesis
• Assessment of LV and RV diastolic function (Pulsed and tissue pulsed Doppler)
• Standards for assessing RV diastolic function (pulse wave Doppler mode)
  • Ve = 75.7 +/- 8.9 cm/sec
  • Va = 48.6 +/- 2.04 cm/sec
  • E/A=1.54 +/-0.19
  • Te = 173.3 +/-11.74 cm/sec
  • IVRT = 81.0 +/-7.24 cm/sec
• M - mode (Penn method)
  • LV myocardial mass = 1.04 x ((EDR + IVS d + LVSD d)3 - (EDR) 3) -13.6
  • Or LV MM = (1.04 x MM volume) -13.6
• Assessment of LV remodeling (ESC classification. 2003) Stage 1 - calculation of LV TPV and LV MM
  • Relative left ventricular wall thickness (RWT) = (2 x LV TZL/LV EDR)
  • LV MM = (1.04 x ((KDR + ZSLZh d + MZHD)3-KDRZ) x 0.8 + 0 6
• Assessment of LV remodeling (ESC classification. 2003) stage 2
  • Normal LV geometry MM index no more than 95 g m sq in F and no more than 115 r/m sq in M ​​LVOT less than or equal to 0.42
  • Concentric remodeling of the LV MM index not more than 95 g/m sq in women and not more than 115 g/m sq in M ​​LVOT greater than or equal to 0.42
  • Concentric hypertrophy of the LV MM index more than 95 r/m sq in women and more than 115 r/m sq in M ​​LVOT less than or equal to 0.42
  • Eccentric LV hypertrophy MM index more than 95 r/m sq in women and more than 115 r/m sq in M ​​LVOT less than or equal to 0.42
• LA pressure calculation
  • P LP = BP syst. - systolic pressure gradient of MR flow
• Divergence of the pericardial layers and PZRP Calculation of the volume of fluid in the pericardium according to PZRP. Fluid volume = (0.8 x PZRP - 0.6) 3
• Assessment of ventricular function should be based on a comprehensive analysis of all indicators obtained during echocardiography.
  
  

The book "Echocardiography from Rybakova. M.K."

ISBN: 978-5-88429-227-7

This publication is a revised, modified and fundamentally new textbook, which reflects all modern technologies used in echocardiography, as well as all the main sections of modern cardiology from the perspective of echocardiography. The peculiarity of the publication is an attempt to combine and compare the results of echocardiographic examination of the heart and pathological material in all main sections.

Of particular interest are sections containing new research technologies, such as three- and four-dimensional reconstruction of the heart in real time, tissue Dopplerography. Much attention is also paid to the classic sections of echocardiography - the assessment of pulmonary hypertension, valvular heart defects, coronary heart disease and its complications, etc.

The book presents enormous illustrative material, a large number of diagrams and drawings, and algorithms for tactics of conducting research and diagnostics in all sections of echocardiography.

Of exceptional interest to specialists is a DVD-ROM with a selection of video clips on all main sections of echocardiography, including rare diagnostic cases.

The book helps resolve controversial and pressing issues of echocardiography, allows you to navigate calculations and measurements, and contains the necessary background information.

The book was written by employees of the Department of Ultrasound Diagnostics of the Russian Medical Academy of Postgraduate Education of the Ministry of Health of the Russian Federation (base - S.P. Botkin State Clinical Hospital, Moscow).

The publication is intended for echocardiography specialists, ultrasound and functional diagnostics doctors, cardiologists and therapists.

Chapter 1. Normal anatomy and physiology of the heart

Normal anatomy of the mediastinum and heart

Structure of the chest

Central mediastinum Anterior mediastinum Superior mediastinum

Structure of the pleura

The structure of the pericardium

The structure of the human heart

The structure of the left chambers of the heart

The structure of the left atrium / The structure of the fibrous frame of the heart / The structure of the mitral valve / The structure of the left ventricle / The structure of the aortic valve / The structure of the aorta The structure of the right chambers of the heart The structure of the right atrium / The structure of the tricuspid valve / The structure of the right ventricle /

Structure of the pulmonary valve / Structure of the pulmonary artery

Blood supply to the heart

Innervation of the heart

Normal cardiac physiology

Chapter 2. Heart examination is normal. B-mode. M-mode.

Standard echocardiographic approaches and positions

Parasternal access

Parasternal position, long axis of the left ventricle Parasternal position, long axis of the right ventricle

Parasternal position, short axis at the level of the end of the aortic valve leaflets Parasternal position, long axis of the pulmonary artery trunk Parasternal position, short axis at the level of the end of the mitral valve leaflets Parasternal position, short axis at the level of the ends of the papillary muscles

Apical access

Apical four-chamber position Apical five-chamber position Apical two-chamber position Long axis of the left ventricle

Subcostal access

Long axis of the inferior vena cava

Long axis of the abdominal aorta

Short axis of the abdominal aorta and inferior vena cava

Subcostal four-chamber position

Subcostal five-chamber position

Subcostal position, short axis at the level of the ends of the aortic valve leaflets Subcostal position, short axis at the level of the ends of the mitral valve leaflets Subcostal position, short axis at the level of the ends of the papillary muscles

Suprasternal access

Suprasternal position, long axis of the aortic arch Suprasternal position, short axis of the aortic arch Examination of the pleural cavities

Standard echocardiographic measurements and guidelines

Chapter 3. Doppler echocardiography is normal. Standard measurements and calculations

Pulsed Wave (PW)

Transmitral diastolic flow

Blood flow in the left ventricular outflow tract

Transtricuspid diastolic flow

Blood flow in the outflow tract of the right ventricle

Blood flow in the ascending aorta

Blood flow in the thoracic descending aorta

Blood flow in the pulmonary veins

Blood flow in the hepatic veins

High pulse repetition rate mode

Continuous wave doppler

Color Doppler

M-color mode

Power Doppler

Chapter 4. Tissue Doppler examination. Modern

non-ppler technologies for assessing cardiac function

(Pulsed Wave Tissue Doppler Imaging - PW TDI)

Tissue Myocardial Doppler (TMD)

CURVED OR CURVED TISSUE COLOR DOPPLER (or C-Color)

DOPPLER ASSESSMENT OF DEFORMATION AND STRAIN RATE (Strain and Strain rate)

"CURVE" OR CURVED STRAIN MODE (or C-Strain gaye)

Tissue Tracking (TT)

VECTOR SPEED IMAGE OR VECTOR ANALYSIS MODE

ENDOCARDIAL MOVEMENT (Vector Velocity Imaging - VVI)

SPOT TRACKING MODE (or Speckle Tracking)

Chapter 5. Three-dimensional and four-dimensional echocardiography.

Clinical capabilities of the method

Possibilities of three-dimensional echocardiography in clinical practice

Real-time assessment of left ventricular systolic function and analysis of its parameters with construction of a volumetric model of the left ventricle and quantitative assessment of global and local contractility

Detailed assessment of the condition of heart valves in the presence of a defect with modeling of the valve opening Assessment of the condition of a prosthetic valve or occluder Assessment of congenital heart defects

Assessment of space-occupying lesions of the heart and mediastinum, including vegetations

for infective endocarditis Assessment of patients with pathology of the pericardium and pleura Assessment of aortic intimal detachment

Assessment of patients with complications of coronary heart disease 3D-Strain - volumetric assessment of left ventricular tissue deformation Assessment of the myocardium Four-dimensional reconstruction of the heart

Chapter 6. Minor anomalies of heart development. Open oval window.

Features of echocadiographic examination in children and adolescents. Prolapse of heart valves

MINOR ANOMALIES OF HEART DEVELOPMENT

NORMAL ANATOMICAL FORMATIONS THAT CAN BE TAKEN AS PATHOLOGICAL

FEATURES OF ECHOCARDIOGRAPHIC STUDIES IN CHILDREN AND ADOLESCENTS

Possible causes of diagnostic errors in children and adolescents during

echocardiographic examination

Standard measurements in children and adolescents

Causes of functional noises in children

PROLABATION OF HEART VALVES

Prolapse of the mitral valve leaflets

Etiology of pathological mitral valve prolapse (Otto C., 1999)

Mitral valve prolapse syndrome / Myxomatous degeneration of valve leaflets / Secondary mitral valve prolapse Assessment of the degree of mitral valve prolapse by the degree of leaflet sagging

(Mukharlyamov N.M., 1981)

Prolapse of the aortic valve leaflets

Etiology of pathological aortic valve prolapse

Prolapse of the tricuspid valve leaflets

Etiology of tricuspid valve prolapse

Prolapse of the pulmonary valve leaflets

Etiology of pathological pulmonary valve prolapse

Chapter 7. Mitral valve

MITRAL REGURGITATION

Etiology

Congenital mitral regurgitation Acquired mitral regurgitation

Inflammatory lesions of the mitral valve leaflets / Degenerative changes in the leaflets / Impaired function of the subvalvular structures and fibrous ring / Other causes

Classification of mitral regurgitation

Acute mitral regurgitation Chronic mitral regurgitation

Hemodynamics in mitral regurgitation

Criteria for assessing the degree of mitral regurgitation by the percentage ratio of the jet area and the area of ​​the left atrium (IV degree of regurgitation) / Criteria for assessing the degree of mitral regurgitation by the percentage ratio of the jet area and the area of ​​the left atrium (III degree of regurgitation). Classification by H. Feigenbaum / Criteria for assessing the degree of mitral regurgitation by jet area / Criteria for assessing the degree of mitral regurgitation by the percentage ratio of the jet area and the area of ​​the left atrium (III degree of regurgitation). Classification of the American and European Associations of Echocardiography / Criteria for assessing the degree of mitral regurgitation according to the radius of the proximal part of the regurgitant jet (PISA) / Criteria for assessing the degree of mitral regurgitation according to the width of the minimum part of the converging flow (vena contracta)

Methods for assessing the degree of mitral regurgitation

Calculation of the rate of increase in pressure in the left ventricle at the beginning of systole

(continuous wave Doppler) Calculation of regurgitant volume fraction using the continuity equation Calculation of regurgitant volume, area and volume of proximal regurgitant jet, effective regurgitant volume Calculation of proximal regurgitant jet area (PISA) / Calculation of proximal regurgitant jet volume / Calculation of effective regurgitant volume / Calculation of regurgitant shock volume Correlation between the degree of mitral regurgitation and the effective regurgitant area Measurement of the minimum portion of converging flow (vena contracta) and assessment of the significance of the mitral

regurgitation according to this indicator Calculation of pressure in the left atrium based on the flow of mitral regurgitation Systolic vibration of the mitral valve leaflets

Assessment of the degree of mitral regurgitation using color Doppler (ratio of the jet area to the atrium area) according to H. Feigenbaum:

MITRAL

REGURGITATION (MORE THAN 1st DEGREE)

MITRAL STENOSIS

Etiology

Congenital mitral stenosis Acquired mitral stenosis

Hemodynamics in mitral stenosis

B- and M-modes

Methods for assessing the degree of mitral stenosis

Measuring the diameter of transmitral diastolic flow in color Doppler mode Criteria for assessing the degree of mitral stenosis depending on the area of ​​the mitral orifice Assessing the degree of significance of mitral stenosis based on the maximum and average pressure gradient Calculation of the area of ​​the mitral orifice

Assessment of the state of the mitral valve in three-dimensional echocardiography DIFFERENTIAL DIAGNOSTICS IN ACCELERATION OF BLOOD FLOW

ON THE MITRAL VALVE IN DIASTOLE

Chapter 8. Aortic valve

AORTAL REGURGITATION

Etiology

Congenital pathology of the aortic valve Acquired pathology of the aortic valve

Classification of aortic regurgitation

Acute aortic regurgitation Chronic aortic regurgitation

Hemodynamics in aortic regurgitation

Research technology

B- and M-modes

Echocardiographic signs of aortic regurgitation Pulsed wave Doppler

Assessing the degree of aortic regurgitation using pulsed wave Doppler Continuous wave Doppler Calculating the half-life of the aortic regurgitation pressure gradient/Calculating left ventricular end-diastolic pressure from the flow of aortic regurgitation Color Doppler

Methods for assessing the degree of aortic regurgitation

Calculation of regurgitant volume fraction using the flow continuity equation

Calculation of the regurgitant volume fraction of aortic regurgitation by diastolic and systolic

phases of flow in the thoracic descending aorta Difficulties in assessing the significance of aortic regurgitation

DIFFERENTIAL DIAGNOSTICS IN THE PRESENCE OF PATHOLOGICAL

AORTAL REGURGITATION (FROM GRADE I)

AORTIC STENOSIS

Etiology

Congenital aortic stenosis Acquired aortic stenosis

Hemodynamics in aortic stenosis

Research technology

B- and M-modes Pulsed wave doppler Continuous wave doppler Color doppler

Methods for assessing aortic stenosis

Hemodynamic assessment of aortic stenosis

Area calculation aortic orifice and assessment of the degree of aortic stenosis DIFFERENTIAL DIAGNOSTICS IN ACCELERATION OF BLOOD FLOW

ON THE AORTIC VALVE IN SYSTOL AND IN THE AORTA

Chapter 9. Tricuspid valve

TRICUSPIDAL REGURGITATION

Etiology

Congenital tricuspid regurgitation Acquired tricuspid regurgitation

Hemodynamics in tricuspid regurgitation

Classification of tricuspid regurgitation

Acute tricuspid regurgitation Chronic tricuspid regurgitation

Research technology

B- and M-modes Pulsed wave Doppler Continuous wave Doppler Color Doppler

Methods for assessing the degree of tricuspid regurgitation

DIFFERENTIAL DIAGNOSTICS FOR PATHOLOGICAL

TRICUSPIDAL REGURGITATION (MORE THAN II DEGREE)

TRICUSPIDAL STENOSIS

Etiology

Congenital tricuspid stenosis Acquired tricuspid stenosis

Hemodynamics in tricuspid stenosis

Research technology

B- and M-modes Pulsed wave Doppler Continuous wave Doppler Color Doppler

Criteria for assessing the degree of tricuspid stenosis

DIFFERENTIAL DIAGNOSTICS IN ACCELERATED BLOOD FLOW AT THE TRICUSPIDAL

Chapter 10. Pulmonary valve

PULMONARY REGURGITATION

Etiology

Congenital pulmonary regurgitation Acquired pulmonary regurgitation

Hemodynamics in pulmonary regurgitation

Research technology

B- and M-modes Pulsed wave Doppler Continuous wave Doppler Color Doppler

Classification of pulmonary regurgitation

Acute pulmonary regurgitation Chronic pulmonary regurgitation

Methods for assessing the degree of pulmonary regurgitation

DIFFERENTIAL DIAGNOSTICS IN THE PRESENCE OF PATHOLOGICAL

PULMONARY REGURGITATION (OVER GRADE II)

PULMONARY VALVE STENOSIS

Etiology

Congenital pulmonary valve stenosis

Acquired pulmonary valve stenosis

Hemodynamics in pulmonary valve stenosis

Research technology

B- and M-modes Pulsed wave Doppler Continuous wave Doppler Color Doppler

Criteria for assessing the degree of pulmonary valve stenosis

DIFFERENTIAL DIAGNOSTICS IN THE PRESENCE OF ACCELERATED BLOOD FLOW

ON THE PULMONARY ARTERY VALVE IN SYSTOL

Chapter 11. Pulmonary hypertension

ETIOLOGY OF PULMONARY HYPERTENSION

Actually pulmonary hypertension

Pulmonary hypertension due to pathology of the left chambers of the heart

Pulmonary hypertension associated with pulmonary

respiratory disease and/or hypoxia

Pulmonary hypertension due to chronic thrombotic

and/or embolic disease

Mixed forms

CLASSIFICATION OF PULMONARY HYPERTENSION

Morphological classification of pulmonary hypertension

Classification of pulmonary hypertension

Primary pulmonary hypertension Secondary pulmonary hypertension

HEMODYNAMICS IN PULMONARY HYPERTENSION

RESEARCH TECHNOLOGY. SIGNS OF PULMONARY HYPERTENSION

B- and M-modes

Dilation of the right heart

The nature of the movement of the interventricular septum Pulse wave Doppler Hypertrophy of the wall of the right ventricle

Change in the pattern of movement of the posterior leaflet of the pulmonary valve in M-mode Mid-systolic covering of the posterior leaflet of the pulmonary valve Diameter of the inferior vena cava and hepatic vein and their response to inspiration

Pulsed wave doppler

Changes in the shape of the flow in the outflow tract of the right ventricle and in the pulmonary artery Presence of pathological tricuspid and pulmonary regurgitation Changes in the shape of the flow curve in the hepatic vein

Continuous wave doppler

Intense flow spectrum of tricuspid regurgitation High flow rate of tricuspid regurgitation

Displacement of the peak flow velocity of tricuspid regurgitation in the first half of systole, V-shaped

flow and the presence of notches in the flow deceleration time Color Doppler

METHODS FOR CALCULATING PULMONARY ARTERY PRESSURE

Calculation of the average pressure in the pulmonary artery in relation to the acceleration time

flow in the outflow tract of the right ventricle to ejection time (AT/ET)

Calculation of the linear velocity integral (VTI) of the flow in the outflow

right ventricular tract

Calculation of the average pressure in the pulmonary artery based on the time of flow acceleration

(AT) in the outflow tract of the right ventricle (Kitabatake formula, 1983)

Calculation of Rs. Aircraft based on the flow acceleration time (AT) in the outflow

right ventricular tract (Mahan formula, 1983)

Calculation of mean pressure in the pulmonary artery based on peak

pulmonary regurgitation pressure gradient (Masuyama, 1986)

Calculation of maximum systolic pressure in the pulmonary

arteries along the flow of tricuspid regurgitation

Calculation of end-diastolic pressure in the pulmonary artery

along the flow of pulmonary regurgitation

Calculation of maximum systolic pressure in the pulmonary artery in pulmonary valve stenosis

Calculation of wedge pressure in the pulmonary artery using pulsed wave and tissue pulsed wave Doppler (Nagueh S.F., 1998)

WAYS TO ASSESS RIGHT ATRIAL PRESSURE

Estimation of right atrial pressure based on degree

dilatation of the inferior vena cava and its response to inspiration

Calculation of pressure in the right atrium using pulse wave and tissue

pulsed wave Doppler (Nageh M.F., 1999)

Empirical assessment of pressure in the right atrium by reversal of flow in the hepatic vein during the atrial systole phase

ASSESSMENT OF THE DEGREE OF PULMONARY HYPERTENSION BASED ON THE OBTAINED CALCULATIONS

RIGHT VENTRICULAR FAILURE

DIFFERENTIAL DIAGNOSTICS IN DILATATION OF THE RIGHT CHAMBERS OF THE HEART

AND WITH HYPERTROPHY OF THE WALL OF THE RIGHT VENTRICLE

Chapter 12. Calculations for assessing ventricular function and myocardial mass.

Research algorithm

CALCULATIONS FOR ASSESSING VENTRICULAR FUNCTION

Assessment of systolic function of the left and right ventricles

Calculation of ventricular volume / Calculation of left ventricular myocardial mass (left ventricular mass) / Left ventricular myocardial mass index / Body surface area (BSA) / Calculation of stroke volume (SV - stroke volume) / Calculation of minute volume of blood flow (CO - cardiac output) / Calculation of ejection fraction (EF- ejection fraction) / Calculation of fraction shortening of myocardial fibers (FS- fraction shortening) / Calculation of relative wall thickness of the left ventricle (RWT - relative wall thickness) / Calculation of stress on the left ventricular wall (left ventricular wall stress) (a)/Calculation of the velocity of circumferential fiber shortening of myocardial fibers (VCF - velocity of circumferential fiber shortening) B-mode

Calculation of ventricular volume / Calculation of left atrium volume / Calculation of left ventricular wall stress (a) / Calculation of myocardial mass in B-mode Pulsed wave Doppler

Flow continuity equation to calculate stroke volume Continuous wave Doppler Calculation of the rate of rise of pressure in the left ventricle at the beginning of systole (dP/dt) / Calculation of the Doppler echocardiographic index (Index), or Tei index, to assess the function of the left and right ventricles (systolic and diastolic) Tissue pulsed wave Doppler Assessment of ventricular systolic function from the rate of systolic displacement of the left or right annulus - Sm / Calculation of left ventricular ejection fraction from the average value of the peak velocity Sm of movement of the mitral valve annulus / Calculation of left ventricular ejection fraction from automatic analysis of three-dimensional simulation of the left ventricle

Assessment of diastolic function of the left and right ventricles

Pulsed wave Doppler Assessment of transmitral and transtricuspid diastolic flow parameters / Study of blood flow in the pulmonary veins to assess diastolic function of the left ventricle / Study of blood flow in the hepatic veins to assess diastolic function of the right ventricle / Assessment of blood flow at the mitral, tricuspid valves and pulmonary veins for the adult population Continuous wave Doppler

Non-invasive calculation of the relaxation time constant (t, Tau) and left ventricular chamber stiffness Color Doppler

Calculation of left ventricular early diastolic filling velocity in color Doppler mode (velocity propogation - Vp) / Estimation of early and late diastolic ventricular filling velocities in M-modal color Doppler mode Tissue pulsed wave Doppler Calculation of left atrial pressure and left ventricular end-diastolic pressure for assessment

ventricular diastolic function

FEATURES OF SYSTOLIC AND DIASTOLIC ASSESSMENT

FUNCTIONS OF THE RIGHT VENTRICLE

Features of assessing right ventricular systolic function

Features of assessing right ventricular diastolic function

IN ASSESSMENT OF SYSTOLIC FUNCTION OF THE LEFT VENTRICLE

M- and B-modes

Pulsed wave doppler

Continuous wave doppler

Tissue color doppler

TACTICS OF ECHOCARDIOGRAPHIC STUDY

IN ASSESSMENT OF SYSTOLIC FUNCTION OF THE RIGHT VENTRICLE

Pulsed wave doppler

Continuous wave doppler

Color Doppler and Color M-mode

Color tissue doppler (Color TDI)

Pulsed Wave Doppler (PW TDI)

TACTICS OF ECHOCARDIOGRAPHIC STUDY

IN ASSESSMENT OF DIASTOLIC FUNCTION OF THE LEFT AND RIGHT VENTRICLES

Pulsed wave doppler

Tissue pulsed wave doppler

Color M-mode Doppler

VARIANTS OF VIOLATION OF DIASTOLIC FUNCTION OF THE LEFT

AND RIGHT VENTRICLES. PHYSIOLOGICAL AGENTS AFFECTING

ON THE DIASTOLIC FUNCTION OF THE VENTRICLES

Variants of disturbance of diastolic function of the left and right ventricles

Physiological agents affecting diastolic function

Chapter 13. Coronary heart disease and its complications

ETIOLOGY

HEMODYNAMICS

RESEARCH TECHNOLOGY

M- and B-modes

Assessment of global myocardial contractility of the left and right ventricles

(assessment of systolic function) Assessment of local myocardial contractility (diagnosis of zones

disturbances of local contractility) Division of the left ventricular myocardium into segments Blood supply to the left ventricular myocardium Calculation of the contractility index to assess the degree of impairment of the systolic function of the left ventricle

Pulsed wave doppler

Continuous wave doppler

Color Doppler

Tissue color doppler

Tissue pulsed wave doppler

ECHOCARDIOGRAPHIC CHANGES IN PATIENTS

CORONARY HEART DISEASE

Angina pectoris

Unstable angina

Myocardial infarction without pathological Q wave

Small focal myocardial infarction

Intramural or subendocardial widespread myocardial infarction

Myocardial infarction with pathological Q wave

Large focal non-advanced myocardial infarction Large focal widespread myocardial infarction

COMPLICATIONS OF MYOCARDIAL INFARCTION

Aneurysm formation

Thrombosis of the left ventricular cavity during myocardial infarction

Dressler syndrome

Rupture of the interventricular septum with the formation of an acquired defect

Spontaneous contrast effect or blood stagnation

Papillary muscle dysfunction

Tear or dissection of the myocardium

Rupture of the free wall of the left ventricle during myocardial infarction

and hemotamponade of the heart

Right ventricular myocardial infarction

FEATURES OF ECHOCARDIOGRAPHIC STUDIES IN PATIENTS

WITH INTRAVENTRICULAR CONDUCTIVITY IMPAIRMENT

FEATURES OF ECHOCARDIOGRAPHIC STUDY

IN PATIENTS WITH A PACETEAMER

SELECTION OF CARDIAC PACING MODE USING DOPPLER ECHOCARDIOGRAPHY

ACUTE LEFT VENTRICULAR FAILURE

POSSIBILITIES OF TRANSTHORACAL ECHOCARDIOGRAPHY

IN THE STUDY OF CORONARY ARTERIES

ECHOCARDIOGRAPHIC ASSESSMENT OF PATIENTS WITH SEVERE CARDIAC PATIENTS

FAILURE AND INDICATIONS FOR RESYNCHORONIZING THERAPY

DIFFERENTIAL DIAGNOSTICS FOR DIFFERENT VARIANTS OF MOVEMENT DISORDERS

WALLS OF THE VENTRICLES AND INTERVENTRICULAR SEPTUM

Chapter 14. Cardiomyopathies and secondary cardiac changes

against the background of various pathologies

DILATATION CARDIOMYOPATHIES

Classification of dilated cardiomyopathies

Primary, congenital or genetic dilated cardiomyopathies Acquired or secondary dilated cardiomyopathies

Etiology of acquired dilated cardiomyopathies

Echocardiographic signs of dilated cardiomyopathies

M-mode B-mode

Pulsed wave Doppler Continuous wave Doppler Color Doppler

Tissue pulsed wave doppler

HYPERTROPHIC CARDIOMYOPATHIES

Etiology of hypertrophic cardiomyopathies

Congenital or genetic Acquired

Types of hypertrophic cardiomyopathy

Non-obstructive Obstructive

Types of hypertrophic cardiomyopathy

Asymmetrical hypertrophy Symmetrical hypertrophy

Assessment of changes in the left ventricle in patients with hypertrophic cardiomyopathy

Non-obstructive hypertrophic cardiomyopathy

Research technology and echocardiographic features M-mode / B-mode / Pulsed wave Doppler / Continuous wave Doppler / Color Doppler / Tissue pulsed wave Doppler

Obstructive hypertrophic cardiomyopathy or subaortic stenosis

Hemodynamics in obstructive hypertrophic cardiomyopathy Research technology and echocardiographic signs M-mode / B-mode / Pulsed wave Doppler / Continuous wave Doppler / Color Doppler / Tissue pulsed wave Doppler

RESTRACTIVE CARDIOMYOPATHIES

Classification of restrictive cardiomyopathies

Primary restrictive cardiomyopathies Secondary restrictive cardiomyopathies Infiltrative restrictive cardiomyopathies

Research technology and echocardiographic signs

M-mode B-mode

Pulsed wave Doppler Continuous wave Doppler Color Doppler

Tissue pulsed wave Doppler ECHOCARDIOGRAPHIC CHANGES IN THE HEART

IN WOMEN DURING PREGNANCY

ECHOCARDIOGRAPHIC CHANGES

FOR ARTERIAL HYPERTENSION

ECHOCARDIOGRAPHIC CHANGES IN CHRONIC

OBSTRUCTIVE PULMONARY DISEASES

ECHOCARDIOGRAPHIC CHANGES IN THROMBOEMBOLISM

PULMONARY ARTERY

ECHOCARDIOGRAPHIC CHANGES DURING CHRONIC

RENAL FAILURE

AGE CHANGES IN THE HEART

CHANGES IN THE HEART IN PATIENTS WITH LONG-EXISTING

ATRIAL FILTER

CHANGES IN THE HEART IN PATIENTS WITH SYSTEMIC DISEASES

(SYSTEMIC LUPUS ERYTHEMATOSUS, SCLERODERMA, ETC.)

CHANGES IN THE HEART IN AMYLOIDOSIS

CHANGES IN THE HEART DURING LONG-TERM EXISTING CONSTANT

ELECTROCARDIAC pacemaker

CHANGES IN THE HEART IN PATIENTS WITH INSULIN-DEPENDENT DIABETES MELLITUS

CHANGES IN THE HEART IN MYOCARDITIS

CHANGES IN THE HEART DUE TO SMOKING

CHANGES IN THE HEART IN PATIENTS AFTER

CHEMOTHERAPY OR RADIATION THERAPY

CHANGES IN THE HEART RESULTING FROM EXPOSURE TO TOXIC AGENTS

CHANGES IN THE HEART AND AORTA IN SYPHILIS

CHANGES IN THE HEART IN HIV-INFECTED PATIENTS

CHANGES IN THE HEART IN SARCOIDOSIS

CHANGES IN THE HEART IN CARCINOID LESIONS

(CARCINOID HEART DISEASE)

DIFFERENTIAL DIAGNOSTICS IN CARDIAC CHAMBER DILATATION

AND WITH HYPERTROPHY OF THE WALLS OF THE LEFT VENTRICLE

Chapter 15. Pathology of the pericardium and pleura

PERICARDIAL PATHOLOGY

Fluid in the pericardial cavity (pericarditis)

Etiology of pericarditis Hemodynamic changes in pericarditis Research technology M- and B-modes / Pulsed wave Doppler / Continuous wave Doppler / Color Doppler / Tissue pulsed wave Doppler

Cardiac tamponade

Hemodynamics in cardiac tamponade Research technology M- and B-modes / Pulsed wave Doppler / Continuous wave Doppler / Color Doppler / Tissue pulsed wave Doppler

Constrictive pericarditis

Etiology of constrictive pericarditis

Pathomorphological classification of constrictive pericarditis

Hemodynamics in constrictive pericarditis Research technology M-mode / B-mode / Pulsed wave Doppler / Continuous wave Doppler / Color Doppler / Tissue pulsed wave Doppler

Exudative-constrictive pericarditis

Adhesive pericarditis

Pericardial cyst

Congenital absence of pericardium

Primary and secondary pericardial tumors

Ultrasound-guided pericardiocentesis

Errors in diagnosing pericarditis

STUDY OF FLUID IN THE PLEURAL CAVITIES

Calculation of the amount of fluid in the pleural cavities

Assessment of the echogenicity of the fluid and the condition of the pleura

DIFFERENTIAL DIAGNOSIS OF PERICARDIAL AND PLEURAL PATHOLOGY

Chapter 16. Pathology of the aorta. Intimal detachment of the aorta

ETIOLOGY OF AORTIC DISEASES

Congenital pathology of the aortic wall

Acquired pathology of the aortic wall

RESEARCH TECHNOLOGY

Pulsed wave doppler

Continuous wave doppler

Color Doppler

Tissue pulsed wave doppler

CLASSIFICATION OF PATHOLOGY OF THE AORTA

Aneurysm of sinus of Valsalva

Aortic root abscess

Aortic aneurysm

Aneurysm of the thoracic ascending aorta

Aortoanular ectasia

False aortic aneurysm

Intimal detachment of the aorta

Classifications of aortic intimal detachment Echocardiographic signs of aortic intimal detachment

DIFFERENTIAL DIAGNOSTICS OF AORTIC INTIMAL DETACHMENT

AND DILATATION OF THE AORTA IN THE ASCENDING THORANDS

Chapter 17. Infective endocarditis and its complications

ETIOLOGY OF INFECTIOUS ENDOCARDITIS

PATHOPHYSIOLOGY OF INFECTIOUS ENDOCARDITIS

Morphological aspects of endocardial and myocardial pathology

Pathomorphological characteristics of vegetation

Frequency of heart valve damage in infective endocarditis

Causative agents of infective endocarditis

CLINICAL AND DIAGNOSTIC CRITERIA FOR INFECTIOUS ENDOCARDITIS

Duke criteria for the diagnosis of infective endocarditis

CLASSIFICATIONS OF INFECTIOUS ENDOCARDITIS

FEATURES OF DAMAGE TO THE VALVULAR APPARATUS

FOR INFECTIOUS ENDOCARDITIS

POSSIBILITIES OF ECHOCARDIOGRAPHY IN INFECTIOUS ENDOCARDITIS

Research technology

Pulsed wave Doppler Continuous wave Doppler Color Doppler

Tissue pulsed wave Doppler Diagnosed complications of infective endocarditis

using echocardiography

Complications with damage to the mitral and tricuspid valves Complications with damage to the aortic valve and pulmonary valve Other complications of infective endocarditis Non-valvular damage with infective endocarditis

FEATURES OF INFECTIOUS ENDOCARDITIS

Endocarditis due to congenital heart defects

Endocarditis on prosthetic heart valves

Endocarditis due to acquired heart defects

Endocarditis due to syphilis and HIV infection

Endocarditis affecting the right chambers of the heart

Endocarditis in patients on hemodialysis

and peritoneal dialysis

Endocarditis in patients over 70 years of age

Endocarditis in patients with a permanent pacemaker

TRANESOCHAGAL ECHOCARDIOGRAPHY IN THE DIAGNOSIS OF INFECTIOUS

ENDOCARDITIS AND ITS COMPLICATIONS

ANATOMICAL FORMATIONS THAT MAY BE

MISTAKEN FOR VEGETATION

OTHER VALVE LEAF CHANGES SIMULATE VEGETS

ALGORITHMS FOR ULTRASONIC DIAGNOSIS OF INFECTIOUS ENDOCARDITIS

AND TACTICS OF PATIENT MANAGEMENT

Echocardiography is a method for studying and diagnosing disorders of the morphology and mechanical activity of the heart, based on recording ultrasound signals reflected from the moving structures of the heart.

Ultrasound imaging of cardiac structures is based on the reflection of ultrasonic waves at the interface between two substances with different physical properties, such as blood and endocardium. Since the angle of incidence is equal to the angle of reflection, the resulting image is specular.

Ultrasound examination of the heart is an indispensable technique for diagnosing diseases of the cardiovascular system. Currently, this study requires the use of Doppler techniques, which include recording blood flows moving through the heart valves in the form of a spectrogram (graph of speed versus time) and a color cartogram of blood flow. Modern high-tech ultrasound methods for studying the heart (tissue Doppler echocardiography, stress echocardiography, transesophageal echocardiography) are much more labor-intensive, but in some cases they are more informative and even irreplaceable.

Using this method, ultrasound diagnostics of such pathological conditions as acquired and congenital heart defects, inflammatory lesions (endocarditis, myocarditis, pericarditis), dilated and hypertrophic cardiomyopathies, diagnosis of kinetic myocardial dysfunction, the presence of intracavitary and pericardial formations (benign and malignant heart tumors, mediastinal formations). Echocardiography is also the only reliable method for diagnosing valvular heart defects (congenital or acquired - rheumatic, postendocardial, atherosclerotic), as well as most known congenital heart defects. The method allows for dynamic monitoring of patients with heart defects and prompt indications for their surgical correction.

Indications for EchoCG

1) heart murmur;

2) pathological changes on a chest x-ray: enlargement of the heart or its individual cavities; changes in the aorta; calcifications in the heart area;

3) chest pain (especially unexplained);

4) fainting and cerebrovascular accidents (especially in young patients);

5) rhythm disturbances;

6) fever of unknown origin;

7) family history of sudden death, ischemic heart disease, idiopathic hypertrophic subaortic stenosis;

8) observation of patients: with ischemic heart disease, including myocardial infarction; with arterial hypertension; with acquired and congenital heart defects; with cardiomyopathies; after cardiac surgery; with non-cardiac pathology - shock, chronic renal failure, systemic connective tissue diseases, when taking cardiotoxic drugs.

One-dimensional echocardiography

With one-dimensional echocardiography, the movement of the heart elements is studied from one point using different angles

sensor tilt from 4 main standard positions according to N.Feigenbaum

In position I, a small part of the right ventricle, the interventricular septum, and the cavity of the left ventricle at the level of the tendon filaments of the mitral valve are sequentially visualized. In this position, the dimensions of the cavity of the left and right ventricles are determined, the thickness and nature of movement of the interventricular septum and the posterior wall of the left ventricle are assessed.

In position II, the ultrasound beam passes through the right ventricle, the interventricular septum, the anterior and posterior leaflets of the mitral valve and the posterior wall of the left ventricle. This position is used to determine the anatomical structure and nature of movement of the mitral leaflets.

The third standard position is formed by directing the beam through the base of the anterior leaflet of the mitral valve, while the segment of the left ventricle in the area of ​​the outflow tract and part of the left atrium cavity fall into the location zone.

IV standard position is formed when the beam passes through the outflow tract of the right ventricle, the aortic root, aortic valves and the cavity of the left atrium. Positions III and IV are highly informative in the diagnosis of aortic stenosis, subaortic stenosis, and aortic valve pathology.

2D echocardiography

Two-dimensional echocardiography significantly complements and clarifies the information about the nature of heart damage obtained using the one-dimensional technique. The examination of the heart is carried out in standard planes along the long, short axis and in the plane of 4 chambers, using parasternal (most often), suprasternal, apical, subcostal projections. Two-dimensional echocardiography allows you to characterize the morphological right and left ventricles, identify the pathology of the atrioventricular valves, the size and location of the ventricular septal defect, obstruction of the left ventricular outflow tract, and the pathology of the semilunar valves.

Doppler echocardiography

Doppler echocardiography is a method that allows non-invasive assessment of central hemodynamic parameters. The use of Doppler studies requires high technical skill in conducting two-dimensional studies, knowledge of topographic anatomy and hemodynamics of the heart. It should be remembered that all Doppler measurements depend on the scanning angle, so correct determination of velocity is only possible when the direction of the ultrasound beam and the movement of the object are parallel. If the ultrasonic beam passes at an angle or orthogonal to the direction of motion of the object, the measured velocities will be less than the true ones by the cosine of the angle between them.

The following Doppler ultrasound options are used:

1. pulse-wave
2. high pulse repetition rate mode
3. continuous wave
4. color
5. M color mode
6. energetic
7. Tissue (tissue color, tissue nonlinear Doppler, tissue pulsed wave, tissue trace, Doppler assessment of strain and strain rate, vector analysis of endocardial movement).

Indications for the use of Doppler echocardiography

localization of heart murmurs; differential diagnosis of organic and functional noises; quantitative assessment of the severity of valve stenosis; determination of blood regurgitation on the valve; determination of intra- and extracardiac blood shunts; determination of pressure values ​​in the cavities of the heart.

Transesophageal echocardiography

Modern echocardiography has a number of varieties, one of which is transesophageal echocardiography.

The method gains greater resolution due to the close proximity of the ultrasound sensor to the heart

Due to its high resolution, esophageal echocardiography plays an important role in the morphological and functional study of valves. Assessing the condition of the mitral valve (including artificial) is one of the most important indications for esophageal echocardiography.

Thus, the most important indications for performing esophageal echocardiography are:

1. A thorough assessment of the condition of natural and artificial valves; examination of the left and right atria and interatrial septum; examination of the thoracic aorta.
2. Evaluation of natural or artificial valve function during heart valve surgery.
3. Control assessment of left ventricular function during major operations; examination for congenital heart defects.
4. Examination of heart valves.
5. Suspicion of endocarditis is another important indication for esophageal echocardiography.

Stress echocardiography

Stress echocardiography is a comprehensive non-invasive diagnostic method that allows you to detail myocardial ischemia, determine the basin of a stenotic coronary artery, identify the viability of the myocardium in the area of ​​post-infarction damage, and assess the inotropic reserve of left ventricular contractility.

The main premise underlying the method is the fact that the occurrence of myocardial ischemia is accompanied by impaired contractility of the left ventricle. A prolonged decrease or complete cessation of coronary blood flow leads to the development of acute myocardial infarction. If the disturbance in the blood supply to the myocardium is transient, then the emerging pathological movement of the wall of the left ventricle serves as a marker for determining the location and severity of myocardial ischemia.

Stress echocardiography allows us to study the effect of physical and pharmacological stress on left ventricular myocardial function. Normally, under the influence of stress, the myocardium contracts more strongly. In the case of coronary stenosis, stress can induce myocardial ischemia. This will result in regional wall motion abnormalities that can be detected by echocardiography. Currently, dobutamine is most often used to induce pharmacological stress. Esophageal stress echocardiography is preferred when transthoracic image quality is poor, which is most often the case when the patient is on mechanical respiration. The sensitivity and specificity of esophageal stress echocardiography by atrial electrical stimulation for the detection of coronary stenosis are high (83% and 94%, respectively).

This examination is also very valuable in detecting ischemic mitral valve regurgitation. Regional myocardial ischemia can cause papillary muscle dysfunction or left ventricular dilation, which leads to the development of acute (or worsening of existing) mitral valve regurgitation. This may be the cause of left-sided heart failure with otherwise good systolic function of the left ventricle at rest. Several reasons necessitated the emergence of such a diagnostic method. Firstly, the predictive value of routine stress ECG is low.

Methodology for conducting echocardiography

The research technique is simple, it is carried out by a trained doctor who is well aware of the topography of normal heart structures, the nature of their possible pathological changes in various diseases and the display of normal and changed structures on an echocardiogram at different periods of the cardiac cycle. EchoCG is carried out in synchronous recording with an ECG in one of the standard or unipolar leads, which are selected according to the good expression of the teeth of the ventricular complex.

During the examination, the patient lies on his back or left side. The sensor is placed above the heart in various positions, providing access to the study of different parts of the heart along its long and short axes.

The main approaches are achieved mainly using 4 positions of the sensor, in 3 or 4 intercostal spaces (parasternal access); in the jugular fossa (suprasternal access), at the lower edge of the costal arch in the area of ​​the xiphoid process of the sternum (subcostal access); in the area of ​​the apex beat (apical approach).

From all these positions, a sectoral scan of the heart is performed in a plane that allows maximum visualization of areas of interest. There are basically three planes:

— long axis plane (sagittal plane):

— short axis plane (horizontal);

- a plane passing through 4 chambers of the heart (parallel to the dorsal one and passing at the level of the length of the heart).

It should be noted conditions that interfere with EchoCG:

1. Insufficient contact between the skin and the sensor (transducer) due to clothing, etc.
2. Incorrect position of the patient's body.
3. Presence of respiratory diseases, respiratory failure.
4. A good image may not be obtained if a small child is crying or the patient is acting restless.
5. With the Doppler method, full-fledged signals cannot be obtained if the angle between the direction of blood flow and the Doppler beam

pplera is too big.

Accordingly, to obtain a high-quality ultrasound image, the following requirements must be met: the patient must take a lying position on his left side; to obtain a high-quality image, the patient must hold his breath while inhaling; for patients with pulmonary emphysema, access from the apex of the lung should be chosen; it is easier to examine children when they are sleeping etc.

Standard echocardiographic measurements and guidelines

1 DAC 2.2 - 4.0 cm

2 CDR 3.5 - 5.5 cm

3 IVS in systole 1.0 - 1.5 cm

4 IVS in diastole 0.6 - 1.1 cm

5 Thickness of the posterior wall of the LV in systole 1.0 - 1.6 cm

6 Thickness of the posterior wall of the LV in diastole 0.8 - 1.1 cm

7 Aortic diameter 1.8 - 3.5 cm

8 Diameter of the left atrium 1.8 - 3.5 cm

9 Systolic divergence of AC 1.6 - 2.2 cm

10 KSO 26 - 69 cm3

11 KDO 50 -147 cm3

12 LV stroke volume 40 -130 ml

13 LV ejection fraction 55 - 75%

14 LV myocardial mass 90 - 150 g

16 Thickness of the anterior wall of the pancreas 0.3 - 0.5 cm

Assessment of left ventricular systolic function

LV systolic function is assessed by several indicators, the central place among which is taken by stroke volume (SV) and ejection fraction (EF) of the left ventricle (LV). Teicholz method. Until recently, the calculation of SV, EF and other hemodynamic parameters was carried out on the basis of measurements of the M - modal echocardiogram recorded from the left parasternal approach. For the calculation, the degree of anteroposterior shortening of the LV is taken into account, that is, the ratio of EDR and KSR.

Assessment of regional contractility disorders

Detection of local disturbances in LV contractility using two-dimensional echocardiography is important for the diagnosis of coronary artery disease. The study is carried out from the apical access along the long axis in the projection of the two- and four-chamber heart, as well as from the left parasternal access along the long and short axes.

To clarify the localization of zones of impaired local contractility, the LV and RV myocardium are conventionally divided into segments.

By identifying the zone of disturbance of local myocardial contractility and clarifying its localization, we can assume which of the coronary arteries is damaged.

- Left anterior descending artery - violation of local contractility in the area of ​​the anterior septum, anterior wall, anterior LV apex. When the diagonal branches are damaged, a violation of contractility in the area of ​​the lateral wall “joins.” If the anterior descending artery supplies the entire apex, the apical segments of the posterior and posterolateral walls will be affected. Depending on the level of damage to the artery, it is possible to identify zones of impaired local contractility in one or another part of the left ventricle.

When the lesion is localized in the distal third of the vessel, only the apex is affected, in the middle third of the vessel - the middle section of the left ventricle and apical segments, in the proximal section - the entire wall, including the basal sections of the myocardium.

— Damage to the circumflex artery leads to an abnormality of local contractility in the area of ​​the lateral and posterior walls of the LV.

In this case, individual characteristics of the blood supply to the myocardium are possible.

— Damage to the posterior descending artery leads to impaired local contractility in the region of the posterior wall of the LV.

— The right coronary artery supplies blood, as a rule, to the RV and the posterior part of the IVS.

In each of these segments, the nature and amplitude of myocardial movement, as well as the degree of its systolic thickening, are assessed. There are 3 types of local disorders of the contractile function of the LV, united by the concept of “asynergy”

The main causes of local disturbances in LV myocardial contractility are:

1. Myocardial infarction.
2. Post-infarction cardiosclerosis.
3. Transient painful and silent myocardial ischemia, including ischemia induced by functional stress tests.

1. Constant ischemia of the myocardium, which has still retained its viability (the so-called “hibernating myocardium”).

1. Dilated and hypertrophic cardiomyopathies, which are often also accompanied by uneven damage to the LV myocardium.

1. Local disturbances of intraventricular conduction (blockade, WPW syndrome, etc.).
2. Paradoxical movements of the IVS, for example, with volume overload of the RV or bundle branch blocks.

Normokinesis - all areas of the endocardium thicken evenly during systole.

Hypokinesis is a decrease in thickening of the endocardium and myocardium in one of the zones during systole compared to other areas. Hypokinesis can be diffuse and local. Local hypokinesis is usually associated with small-focal or intramural myocardial damage. Hypokinesis can be a consequence of frequent ischemia in any zone (hibernating myocardium) and be transient.

Akinesis is the absence of thickening of the endocardium and myocardium during systole in one of the areas. Akinesia, as a rule, indicates the presence of a large-focal lesion. Against the background of significant dilatation of the heart chambers, it is impossible to reliably judge the presence of an akinesia zone.

Dyskinesis is a paradoxical movement of a section of the heart muscle during systole (bulging). Dyskinesis is characteristic of an aneurysm.

Variants of myocardial contractility.

The most pronounced disturbances of local myocardial contractility are detected in acute myocardial infarction, post-infarction cardio-

sclerosis and LV aneurysm.

Violations of local contractility of individual segments of the LV in patients with coronary artery disease are usually described on a five-point scale:

1 point - normal contractility;

2 points - moderate hypokinesia (slight decrease in the amplitude of systolic movement and thickening in the study

blown area);

3 points - severe hypokinesia;

4 points - akinesia;

5 points - dyskinesia (systolic movement of the myocardium of the segment under study occurs in the direction opposite

false normal).

Assessment of left ventricular diastolic function

Diastolic function of the left ventricle is determined by two properties of the myocardium - relaxation and rigidity. From a clinical point of view, diastole is the period lasting from the moment the sides of the aortic valve close until the first heart sound occurs. Hemodynamically, diastole can be divided into four phases:

1) isovolumic relaxation (from the moment of closure of the aortic valve leaflets to the beginning of transmitral blood flow);

2) rapid filling phase;

3) slow filling phase;

4) atrial systole.

Diastolic dysfunction can occur with isolated disorders of any of the phases and with their combination.

In recent years, great importance in the development of congestive heart failure has been attached to disturbances in LV diastolic function, caused by increased rigidity (decreased compliance) of the myocardium during diastolic filling. The causes of LV diastolic dysfunction are cardiosclerosis, chronic ischemia, compensatory myocardial hypertrophy, inflammatory, dystrophic and other changes in the heart muscle, which lead to a significant slowdown in LV relaxation. The amount of preload also matters.

LV diastolic function is assessed by the results of a study of transmitral diastolic blood flow in pulsed Doppler mode. Define parameters:

1) the maximum speed of the early peak of diastolic filling (Vmax Peak E);

2) the maximum speed of transmitral blood flow during systole of the left atrium 1 (Vmax Peak A);

3) area under the curve (velocity integral) of early diastolic filling (MVVTI Peak E) and 4) atrial systole (MV VTI Peak A);

5) the ratio of the maximum speeds (or speed integrals) of early and late filling (E/A);

6) LV isovolumic relaxation time - IVRT (IsoVolumic Relaxation Time);

7) early diastolic filling deceleration time (DT).

Damage to the valvular apparatus of the heart

allows you to identify:

1) fusion of valve leaflets;

2) insufficiency of one or another valve (including signs of regurgitation);

3) dysfunction of the valve apparatus, in particular the capillary muscles, leading to the development of prolapse of the valves;

4) the presence of vegetations on the valve leaflets and other signs of damage.

Mitral stenosis

Currently, echocardiography is the most accurate and accessible non-invasive method for diagnosing mitral stenosis. EchoCG makes it possible to assess the condition of the MV valves, the area of ​​the left atrioventricular orifice (degree of stenosis), the dimensions of the left atrium, and the right ventricle. The method is of great importance in recognizing “aphonic” mitral stenosis.

Examination of a patient with MV stenosis begins with measuring the thickness of the anterior and posterior MV leaflets at the base and ends, as well as the diameter of the MV ring. These indicators are important for deciding on the tactics of patient management, the possibility of performing balloon valvuloplasty or valve replacement. In addition, it is necessary to assess the condition of the chordal apparatus and commissures of the valves. The opening of the MV valves can be measured in M- and B-modal modes. To determine the area of ​​the mitral orifice, the planimetric method is used by tracing the contours of the orifice with a cursor at the moment of maximum diastolic opening of the valve leaflets. The mitral orifice takes the shape of an ellipsoid or fissure. Normally, the area of ​​the mitral orifice is 4-6 cm². An area of ​​less than 1 cm² is considered a sign of critical stenosis of the left atrioventricular orifice (significant stenosis), moderate stenosis is recorded when the mitral orifice area is from 1 to 2 cm², minor stenosis is an area of ​​more than 2 cm².

With MV stenosis, the posterior leaflet is fused to the anterior leaflet, opening is limited. Characteristic is the unidirectional movement of the MV leaflets due to the adhesive process in the area of ​​the commissures and the “parousia” of the anterior leaflet into the diastolic cavity of the LV under blood pressure. With significant calcification, the degree of parousia can be small, but the degree of defect can be significant. With mitral stenosis, the pressure in the left atrium cavity increases, which leads to its dilatation. Thus, with critical mitral stenosis, the volume of the left atrium may exceed 1 liter. With mitral stenosis, atrial fibrillation is often observed, while blood clots can form in the cavity and in the appendage of the left atrium, for the visualization of which transesophageal echocardiography is more informative. Another sign is an increase in the velocity of the transmitral diastolic flow, as well as the registration of accelerated turbulent flow through the mitral valve into the diatolate. The area of ​​the mitral orifice can also be calculated using RNT. PHT (pressure half time) or pressure half-time is the time during which the pressure gradient would decrease by 2 times (normally 50-70 ms); with mitral stenosis, the indicator increases to 110-300 ms or more.

These Doppler echocardiographic signs of mitral stenosis are due to the existence of a pronounced diastolic pressure gradient between the left atrium and the left ventricle and a slow decrease in this gradient during filling of the left ventricle with blood.

Mitral valve insufficiency

Mitral valve insufficiency is the most common pathology of the mitral valve, the clinical manifestations of which are often mild or absent altogether. There are 2 main forms of mitral regurgitation:

1) organic mitral valve insufficiency with wrinkling and shortening of the valve leaflets, calcium deposition and damage to subvalvular structures (rheumatism, infective endocarditis, atherosclerosis, systemic connective tissue diseases);

2) relative mitral insufficiency, caused by dysfunction of the valve apparatus in the absence of gross morphological changes in the valve leaflets.

Causes of relative mitral regurgitation

 MV prolapse;

 IHD, including acute myocardial infarction;

 disease of the left ventricle, accompanied by severe dilatation and expansion of the fibrous ring of the valve and/or dysfunction of the valve apparatus (arterial hypertension, aortic heart defects, cardiomyopathies);

 rupture of tendon threads;

 calcification of the papillary muscles and fibrous ring of the MV.

The only reliable sign of organic mitral regurgitation—non-closure (separation) of the MV valves during ventricular systole—is detected extremely rarely. Indirect echocardiographic signs of mitral regurgitation, reflecting hemodynamic changes characteristic of this defect, include:

1) increase in LA size;

2) hyperkinesia of the posterior wall of the left atrium;

3) increase in total stroke volume;

4) myocardial hypertrophy and dilatation of the LV cavity.

Criteria for assessing the degree of mitral regurgitation are proposed based on the percentage ratio of the jet area and the area of ​​the left atrium; the significance of regurgitation is assessed based on the results obtained:

I degree –< 20% (незначительная);

II degree – 20-40% (moderate);

III degree – 40-80% (significant),

IV degree - > 80% (severe).

Aortic stenosis

There are three main forms of aortic stenosis:

valve (congenital or acquired);

subvalvular (congenital or acquired);

supravalvular (congenital).

Valvular stenosis of the aortic mouth can be congenital or acquired. Congenital aortic stenosis is diagnosed immediately after the birth of the child.

The causes of acquired aortic stenosis are: rheumatic damage to the valve leaflets (most common reason); in this case, the aortic valve leaflets become compacted and deformed at the edges, welded together along the commissures; the defect is often combined and combined with damage to the mitral and other valves.

Atherosclerotic aortic stenosis is common.

Combined with calcification of the left fibrous atrioventricular ring, calcification of the aortic walls. Isolated aortic stenosis, as a rule, indicates a non-rheumatic etiology of the defect. The aortic valve leaflets are calcified, there are no adhesions along the commissures. This type of defect is characterized by an age over 65 years; infective endocarditis. In this case, you can see calcifications at the ends of the valves and adhesive process due to inflammation; primary degenerative changes in valves with subsequent calcification.

With aortic stenosis, the flow of blood from the left ventricle to the aorta is hampered, as a result of which the systolic pressure gradient between the cavity of the left ventricle and the aorta increases significantly. It usually exceeds 20 mm Hg. Art., and sometimes reaches 100 mm Hg. Art. and more.

As a result of this pressure load, the function of the left ventricle increases and its hypertrophy occurs, which depends on the degree of narrowing of the aortic opening. So, if the normal area of ​​the aortic opening is about 3 cm², then reducing it by half causes a pronounced hemodynamic disturbance. Especially severe violations occur when the hole area is reduced to 0.5 cm² Final diastolic pressure may remain normal or slightly increase (up to 10-12 mm Hg) due to impaired relaxation of the left ventricle, which is associated with severe hypertrophy. Due to the large compensatory capabilities of the hypertrophied left ventricle, cardiac output remains normal for a long time, although with exercise it increases less than in healthy individuals.

When symptoms of decompensation appear, a more pronounced increase in end-diastolic pressure and dilatation of the left ventricle are observed.

1. Concentric left ventricular hypertrophy

1. Diastolic dysfunction

1. Fixed stroke volume

1. Coronary perfusion disorders

1. Cardiac decompensation

Aortic insufficiency

Assessment of the degree of aortic regurgitation is carried out using pulsed wave Doppler and is divided into

on the following degrees:

Ι degree - directly under the valves of the AK;

ΙΙ degree - to the end of the anterior valve of the MV;

ΙΙΙ degree - to the ends of the papillary muscles;

ΙV degree - to the apex of the left ventricle.

Tricuspid insufficiency

Infective endocarditis

1. Diagnosing the presence of vegetation.
2. Clarification of the localization of vegetation.
3. Measuring the size of vegetation.
4. Clarification of the nature of vegetation (flat, prolapsing).
5. Diagnosis of complications of infective endocarditis.
6. Establishing the limitation of the process.
7. Non-invasive assessment of central hemodynamic parameters.
8. Quite frequent dynamic observations.

Arterial hypertension

The use of echocardiography in patients with hypertension makes it possible to:

identify objective signs of LV hypertrophy and pro-

conduct its quantitative assessment;

determine the size of the heart chambers;

assess LV systolic function;

assess LV diastolic function;

identify violations of regional contractility of the LV;

in some cases, to identify dysfunctions of the valve apparatus, for example, with the development of relative MV insufficiency.

LV wall thickness should be measured at end diastole.

Criteria for assessing the degree of myocardial hypertrophy based on the thickness of the LV wall at the end of diastole:

1) slight hypertrophy - 12 - 14 mm,

2) moderate - 14 -16 mm,

3) significant - 16 - 18 mm,

4) pronounced - 18 - 20 mm,

5) high degree - more than 20 mm.

IHD

In patients with angina pectoris, calcification of the walls of the aorta and the left fibrous atrioventricular ring can be observed varying degrees, type I disorder of diastolic function of the left ventricle. The LA may be slightly dilated in length. LV systolic function is usually preserved. There are no zones of local contractility impairment.

THEM

IN acute period with a small focal infarction, it is possible to detect hyperkinesis of the myocardium of the intact zone, impaired LV diastolic function of the first type with rapid subsequent normalization during therapy.