echocardiography echocardiography an echocardiography, also known as a cardiac echography (abbreviated to cardiac echo or simply an echo), is an ultrasound of the heart. it is a type of medical imaging of the heart, using standard ultrasound or doppler ultrasound. the visual image formed using this technique is called an echocardiogram. not to be confused with electrocardiography or other types of electrography. echocardiographyan abnormal echocardiogram: image shows a midmuscular ventricular septal defect. the trace in the lower left shows the cardiac cycle and the red mark the time in the cardiac cycle when the image was captured. colors are used to represent the velocity and direction of blood flow.icd-9-cm88.72meshd004452ops-301 code3-052medlineplus003869 echocardiography has become routinely used in the diagnosis, management, and follow-up of patients with any suspected or known heart diseases. it is one of the most widely used diagnostic imaging modalities in cardiology. it can provide a wealth of helpful information, including the size and shape of the heart (internal chamber size quantification), pumping capacity, location and extent of any tissue damage, and assessment of valves. an echocardiogram can also give physicians other estimates of heart function, such as a calculation of the cardiac output, ejection fraction, and diastolic function (how well the heart relaxes). echocardiography is an important tool in assessing wall motion abnormality in patients with suspected cardiac disease. it is a tool which helps in reaching an early diagnosis of myocardial infarction, showing regional wall motion abnormality. also, it is important in treatment and follow-up in patients with heart failure, by assessing ejection fraction. echocardiography can help detect cardiomyopathies, such as hypertrophic cardiomyopathy, dilated cardiomyopathy, and many others. the use of stress echocardiography may also help determine whether any chest pain or associated symptoms are related to heart disease. the biggest advantage of echocardiography is that it is not invasive (does not involve breaking the skin or entering body cavities) and has no known risks or side effects. not only can an echocardiogram create ultrasound images of heart structures, but it can also produce accurate assessment of the blood flowing through the heart by doppler echocardiography, using pulsed- or continuous-wave doppler ultrasound. this allows assessment of both normal and abnormal blood flow through the heart. color doppler, as well as spectral doppler, is used to visualize any abnormal communications between the left and right sides of the heart, any leaking of blood through the valves (valvular regurgitation), and estimate how well the valves open (or do not open in the case of valvular stenosis). the doppler technique can also be used for tissue motion and velocity measurement, by tissue doppler echocardiography. echocardiography was also the first ultrasound subspecialty to use intravenous contrast. echocardiography is performed by cardiac sonographers, cardiac physiologists (uk), or physicians trained in echocardiography. recognized as the "father of echocardiography", the swedish physician inge edler (1911–2001), a graduate of lund university, was the first of his profession to apply ultrasonic pulse echo imaging in diagnosing cardiac disease, which the acoustical physicist floyd firestone had developed to detect defects in metal castings. in fact, edler in 1953 produced the first echocardiographs using an industrial firestone-sperry ultrasonic reflectoscope. in developing echocardiography, edler worked with the physicist carl hellmuth hertz, the son of the nobel laureate gustav hertz and grandnephew of heinrich rudolph hertz. medical uses sonographer doing an echocardiogram of a child echocardiogram in the parasternal long-axis view, showing a measurement of the heart's left ventricle health societies recommend the use of echocardiography for initial diagnosis when a change in the patient's clinical status occurs and when new data from an echocardiogram would result in the physician changing the patient's care. diagnostic criteria for numerous cardiac diseases are based on echocardiography studies. for example, the differentiation of mild, moderate, and severe valvular disease is based upon measured criteria. another example is the estimation of heart function by the left ventricular ejection fraction (lvef) has vast uses including classification of heart failure and cut offs for implantation of implantable cardioverter-defibrillators. health societies do not recommend routine testing when the patient has no change in clinical status or when a physician is unlikely to change care for the patient based on the results of testing. a common example of overuse of echocardiography when not indicated is the use of routine testing in response to a patient diagnosis of mild valvular heart disease. in this case, patients are often asymptomatic for years before the onset of deterioration and the results of the echocardiogram would not result in a change in care without other change in clinical status. echocardiography now has a vast role in pediatrics, diagnosing patients with valvular heart disease and other congenital abnormalities. an emerging branch is fetal echocardiography, which involves echocardiography of an unborn fetus. types there are three primary types of echocardiography: transthoracic, transesophageal, and intracardic. stress testing utilizes tranthoracic echo in combination with an exercise modality (e.g., a treadmill). intravascular ultrasound is included below, but is as the name indicates more "ultrasound" than "echocardiography" as it is imaging the walls of a vessel rather than the heart. transthoracic echocardiogram main article: transthoracic echocardiogram a standard echocardiogram is also known as a transthoracic echocardiogram (tte) or cardiac ultrasound; and it is used for rapid evaluation of a patient at their bedside. in this case, the echocardiography transducer (or probe) is placed on the chest wall (or thorax) of the subject, and images are taken through the chest wall. this is a non-invasive, highly accurate, and quick assessment of the overall function of the heart. tte utilizes several "windows" to image the heart from different perspectives. each window has advantages and disadvantages for viewing specific structures within the heart and, typically, numerous windows are utilized within the same study to fully assess the heart. parasternal long and parasternal short axis windows are taken next to the sternum, the apical two/three/four chamber windows are taken from the apex of the heart (lower left side), and the subcostal window is taken from underneath the edge of the last rib. tte utilizes one- ("m mode"), two-, and three-dimensional ultrasound (time is implicit and not included) from the different windows. these can be combined with pulse wave or continuous wave doppler to visualize the velocity of blood flow and structure movements. images can be enhanced with "contrast" that are typically some sort of micro bubble suspension that reflect the ultrasound waves. transesophageal echocardiogram main article: transesophageal echocardiogram a transesophageal echocardiogram is an alternative way to perform an echocardiogram. a specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus via the mouth, allowing image and doppler evaluation from a location directly behind the heart. it is most often used when transthoracic images are suboptimal and when a clearer and more precise image is needed for assessment. this test is performed in the presence of a cardiologist, anesthesiologist, registered nurse, and ultrasound technologist. conscious sedation and/or localized numbing medication may be used to make the patient more comfortable during the procedure. tee, unlike tte, does not have discrete "windows" to view the heart. the entire esophagus and stomach can be utilized, and the probe advanced or removed along this dimension to alter the perspective on the heart. most probes include the ability to deflect the tip of the probe in one or two dimensions to further refine the perspective of the heart. additionally, the ultrasound crystal is often a two-dimension crystal and the ultrasound plane being used can be rotated electronically to permit an additional dimension to optimize views of the heart structures. often, movement in all of these dimensions is needed. tee can be used as stand-alone procedures, or incorporated into catheter- or surgical-based procedures. for example, during a valve replacement surgery the tee can be used to assess the valve function immediately before repair/replacement and immediately after. this permits revising the valve mid-surgery, if needed, to improve outcomes of the surgery. stress echocardiography main article: cardiac stress test a stress echocardiogram, also known as a stress echo, uses ultrasound imaging of the heart to assess the wall motion in response to physical stress. first, images of the heart are taken "at rest" to acquire a baseline of the patient's wall motion at a resting heart rate. the patient then walks on a treadmill or uses another exercise modality to increase the heart rate to his or her target heart rate, or 85% of the age-predicted maximum heart rate (220 − patient's age). finally, images of the heart are taken "at stress" to assess wall motion at the peak heart rate. a stress echo assesses wall motion of the heart; it does not, however, create an image of the coronary arteries directly. ischemia of one or more coronary arteries could cause a wall motion abnormality, which could indicate coronary artery disease. the gold standard test to directly create an image of the coronary arteries and directly assess for stenosis or occlusion is a cardiac catheterization. a stress echo is not invasive and is performed in the presence of a licensed medical professional, such as a cardiologist, and a cardiac sonographer. intracardiac echocardiography intracardiac echocardiography (ice) is specialized form of echocardiography that uses catheters to insert the ultrasound probe inside the heart to view structures from within the heart. ice is often used as a part of the cardiac procedure of crossing the interatrial septum with a transseptal puncture to permit catheter access from the right atrium to the left atrium; alternative access to the left heart would be retrograde through the aorta and across the aortic valve into the left ventricle. ice has the benefit over transthoracic echocardiography in that an operator who is performing a sterile procedure can also operate the ice catheter and it is not limited to visibility problems that can arise with transthoracic or transesophageal echo. though, there are image quality limitations due to size constraints of the probe being limited to a catheter. ice is often inserted through the femoral vein and into the right atrium. from the right atrium, visualization of the interatrial septum, all four cardiac chambers, all four valves, and the pericardial space (for an effusion) can be readily visualized. it can also be advanced across the atrial septum into the left atrium to visualize the left atrial appendage during left atrial appendage occlusion device deployment. utilization of ice imagery can be incorporated into the 3-d models built with electroanatomic mapping systems. intravascular ultrasound coronary artery ivus with lumen inside yellow line and atherosclerotic plaque in green intravascular ultrasound (ivus) is a specialized form of echocardiography that uses a catheter to insert the ultrasound probe inside blood vessels. this is commonly used to measure the size of blood vessels and to measure the internal diameter of the blood vessel. for example, this can be used in a coronary angiogram to assess the narrowing of the coronary artery. if the catheter is retraced in a controlled manner, then an internal map can be generated to see the contour of the vessel and its branches. modes the various modes listed below essentially describe how the ultrasound crystals are used to obtain information. these modes are common to all types of echocardiography. a-mode amplitude mode is not a mode used in modern echocardiography. b-mode / 2d brightness mode is often synonymous with "2d" and is very commonly used in echocardiography. m-mode motion mode is infrequently used in modern echocardiography. it has specific uses and has the benefit of very high temporal fidelity (e.g., measuring lv size at end diastole). strain rate imaging (deformation echocardiography) main article: strain rate imaging strain rate imaging is an ultrasound method for imaging regional differences in contraction (dyssynergy) in for instance ischemic heart disease or dyssynchrony due to bundle branch block. strain rate imaging measures either regional systolic deformation (strain) or the rate of regional deformation (strain rate). the methods used are either tissue doppler or speckle tracking echocardiography. three-dimensional echocardiography three-dimensional echocardiogram of a heart viewed from the apex three-dimensional echocardiography (also known as four-dimensional echocardiography when the picture is moving) is now possible, using a matrix array ultrasound probe and an appropriate processing system. it enables detailed anatomical assessment of cardiac pathology, particularly valvular defects, and cardiomyopathies. the ability to slice the virtual heart in infinite planes in an anatomically appropriate manner