The esc textbook of cardiovascular imaging 3rd edition jose luis zamorano - Read the ebook online or

Page 1


https://ebookmass.com/product/the-esc-textbook-ofcardiovascular-imaging-3rd-edition-jose-luis-zamorano/

Instant digital products (PDF, ePub, MOBI) ready for you

Download now and discover formats that fit your needs...

ESC Textbook of Cardiovascular Nursing

https://ebookmass.com/product/esc-textbook-of-cardiovascular-nursing/

ebookmass.com

The ESC Textbook of Intensive and Acute Cardiovascular Care 3rd Edition Marco Tubaro (Editor)

https://ebookmass.com/product/the-esc-textbook-of-intensive-and-acutecardiovascular-care-3rd-edition-marco-tubaro-editor/

ebookmass.com

The ESC Textbook of Sports Cardiology 1st Edition Antonio Pelliccia

https://ebookmass.com/product/the-esc-textbook-of-sportscardiology-1st-edition-antonio-pelliccia/

ebookmass.com

Skin Disease E Book: Diagnosis and Treatment 4th Edition, (Ebook PDF)

https://ebookmass.com/product/skin-disease-e-book-diagnosis-andtreatment-4th-edition-ebook-pdf/

ebookmass.com

Just in Time for Christmas Carolyn Brown

https://ebookmass.com/product/just-in-time-for-christmas-carolynbrown-2/

ebookmass.com

The Language of Surrealism 1st ed. Edition Peter Stockwell

https://ebookmass.com/product/the-language-of-surrealism-1st-ededition-peter-stockwell/

ebookmass.com

Beginning ReactJS Foundations Building User Interfaces with ReactJS: An Approachable Guide 1st Edition Chris Minnick

https://ebookmass.com/product/beginning-reactjs-foundations-buildinguser-interfaces-with-reactjs-an-approachable-guide-1st-edition-chrisminnick/

ebookmass.com

The Trace Factory Yves Jeanneret

https://ebookmass.com/product/the-trace-factory-yves-jeanneret/

ebookmass.com

A Hidden Wisdom: Medieval Contemplatives on SelfKnowledge, Reason, Love, Persons, and Immortality

https://ebookmass.com/product/a-hidden-wisdom-medieval-contemplativeson-self-knowledge-reason-love-persons-and-immortality-christina-vandyke/

ebookmass.com

The Greatest Escape: A gripping story of wartime courage and adventure 1st Edition Neil Churches

https://ebookmass.com/product/the-greatest-escape-a-gripping-story-ofwartime-courage-and-adventure-1st-edition-neil-churches/

ebookmass.com

The ESC Textbook of Cardiovascular Imaging

EUROPEAN SOCIETY OF CARDIOLOGY PUBLICATIONS

The ESC Textbook of Cardiovascular Medicine (Third Edition)

Edited by A. John Camm, Thomas F. Lüscher, Gerald Maurer, and Patrick W. Serruys

The ESC Textbook of Preventive Cardiology

Edited by Stephan Gielen, Guy De Backer, Massimo Piepoli, and David Wood

The EHRA Book of Pacemaker, ICD, and CRT Troubleshooting: Case-based learning with multiple choice questions

Edited by Harran Burri, Carsten Israel, and Jean-Claude Deharo

The EACVI Echo Handbook

Edited by Patrizio Lancellotti and Bernard Cosyns

The ESC Handbook of Preventive Cardiology: Putting prevention into practice

Edited by Catriona Jennings, Ian Graham, and Stephan Gielen

The EACVI Textbook of Echocardiography (Second Edition)

Edited by Patrizio Lancellotti, José Luis Zamorano, Gilbert Habib, and Luigi Badano

The EHRA Book of Interventional Electrophysiology: Case-based learning with multiple choice questions

Edited by Hein Heidbuchel, Matthias Duytschaever, and Harran Burri

The ESC Textbook of Vascular Biology

Edited by Robert Krams and Magnus Bäck

The ESC Textbook of Cardiovascular Development

Edited by José Maria Pérez-Pomares and Robert Kelly

The EACVI Textbook of Cardiovascular Magnetic Resonance

Edited by Massimo Lombardi, Sven Plein, Steffen Petersen, Chiara Bucciarelli-Ducci, Emanuela R. Valsangiacomo Buechel, Cristina Basso, and Victor Ferrari

The ESC Textbook of Sports Cardiology

Edited by Antonio Pelliccia, Hein Heidbuchel, Domenico Corrado, Mats Börjesson, and Sanjay Sharma

The ESC Handbook of Cardiac Rehabilitation

Edited by Ana Abreu, Jean-Paul Schmid, and Massimo Piepoli

The ESC Textbook of Intensive and Acute Cardiovascular Care (Third Edition)

Edited by Marco Tubaro, Pascal Vranckx, Eric Bonnefoy-Cudraz, Susanna Price, and Christiaan Vrints

The ESC Textbook of Cardiovascular Imaging (Third Edition)

Edited by José Luis Zamorano, Jeroen J. Bax, Juhani Knuuti, Patrizio Lancellotti, Fausto J. Pinto, Bogdan A. Popescu, and Udo Sechtem

The ESC Textbook of Cardiovascular Imaging

THIRD EDITION EDITED BY

José Luis Zamorano

Jeroen J. Bax

Juhani Knuuti

Patrizio Lancellotti

Fausto J. Pinto

Bogdan A. Popescu

Udo Sechtem

Great Clarendon Street, Oxford, OX2 6DP, United Kingdom

Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries

© European Society of Cardiology 2021

The moral rights of the authors have been asserted

First Edition published in 2010

Second Edition published in 2015

Third Edition published in 2021

Impression: 1

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above

You must not circulate this work in any other form and you must impose this same condition on any acquirer

Published in the United States of America by Oxford University Press

198 Madison Avenue, New York, NY 10016, United States of America

British Library Cataloguing in Publication Data

Data available

Library of Congress Control Number: 2020949297

ISBN 978–0–19–884935–3

DOI: 10.1093/med/9780198849353.001.0001

Printed in Great Britain by Bell & Bain Ltd., Glasgow

Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding

Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

Preface

With great pleasure we would like to introduce the third edition of The ESC Textbook of Cardiovascular Imaging. Cardiovascular imaging is the cornerstone of non-invasive diagnosis in cardiology. The continuous development of all techniques implies the need for continuous medical education.

The third edition of The ESC Textbook of Cardiovascular Imaging includes new and updated chapters that explain the utility of the different imaging modalities in the diagnosis of all relevant and major cardiovascular diseases.

The clinically oriented text is accompanied by images and insights of the everyday practice of these techniques, prepared by experienced and well-known cardiovascular imagers who have dedicated long hours and commitment to prepare the chapters included in this edition.

We hope that cardiologists, trainees, and cardiovascular imagers find in this book the knowledge and expertise to cope with the challenges faced in their daily practice.

As editors, we have tried to harmonize all chapters in order to obtain an easy reading of all chapters. Images were carefully selected to better understand the text. On behalf of all the editors, we would like to express our gratitude to all authors and to Claudia Balseca as Editors’ Assistant. All of them worked extremely hard to make this third book possible.

We want to dedicate our work to the victims of COVID-19 and their families, especially to our beloved friend Prof Maurizio Galderisi, who was a co-author in this book.

José Luis Zamorano

Jeroen J. Bax

Juhani Knuuti

Patrizio Lancellotti

Fausto J. Pinto

Bogdan A. Popescu

Udo Sechtem

Free personal online access for five years

Individual purchasers of this book are also entitled to free personal access to the online edition for 5 years via oxfordmedicine.com/esccvimaging3. Please refer to the access token for instructions on token redemption and access.

Accessing this content online allows you to print, save, cite, email, and share content; download high-resolution figures as PowerPoint® slides; save often-used books, chapters, or searches; annotate; and quickly jump to other chapters or related material on a mobile-optimized platform.

Symbols and abbreviations xi

Contributors xv

SECTION 1

Technical aspects of imaging

1 Conventional echocardiography—basic principles 3

Andreas Hagendorff, Stephan Stobe, and Bhupendar Tayal

2 Nuclear cardiology (PET and SPECT)—basic principles 41

Danilo Neglia, Riccardo Liga, Stephan G. Nekolla, Frank M. Bengel, Ornella Rimoldi, and Paolo G. Camici

3 Cardiac CT—basic principles 57

Gianluca Pontone and Filippo Cademartiri

4 CMR—basic principles 67

Jan Bogaert, Rolf Symons, and Jeremy Wright

5 Training and competence in cardiovascular imaging 79

Kevin Fox and Marcelo F. Di Carli

SECTION 2

New technical developments in imaging techniques

6 New developments in echocardiography/ Advanced echocardiography 87

6.1 Three-dimensional echocardiography 87

Silvia Gianstefani and Mark J. Monaghan

6.2 Assessment of myocardial function by speckle-tracking echocardiography 103

Thor Edvardsen, Lars Gunnar Klaeboe, Ewa Szymczyk, and Jarosław D. Kasprzak

7 Contrast echocardiography 111

Roxy Senior, Harald Becher, Fausto J. Pinto, and Rajdeep S. Khattar

8 Echocardiography in the cath lab: Fusion imaging and use of intracardiac echocardiography 121

Covadonga Fernández-Golfín and José Luis Zamorano

9 New technical developments in nuclear cardiology and hybrid imaging 129

Antti Saraste, Sharmila Dorbala, and Juhani Knuuti

10 New technical developments in Cardiac CT: Anatomy, fractional flow reserve (FFR), and machine learning 145

Stephan Achenbach, Jonathan Leipsic, and James Min

SECTION 3

Valvular heart disease

11 Aortic valve stenosis 161

Philippe Pibarot, Helmut Baumgartner, Marie-Annick Clavel, Nancy Côté, and Stefan Orwat

12 Aortic valve regurgitation 181

Julien Magne and Patrizio Lancellotti

13 Mitral valve stenosis 191

Ferande Peters and Eric Brochet

14 Mitral valve regurgitation 199

Daniel Rodríguez Muñoz, Kyriakos Yiangou, and José Luis Zamorano

15 Tricuspid and pulmonary valve disease 211

Denisa Muraru and Elif Leyla Sade

16 Multiple and mixed valvular heart disease 223

Philippe Unger and Madalina Garbi

17 Intraoperative transoesophageal echocardiography for valvular surgery 233

Joseph F. Maalouf and Hector I. Michelena

18 Valvular prostheses 251

Luigi P. Badano and Denisa Muraru

19 Endocarditis 271

Daniel Rodríguez Muñoz and Álvaro Marco del Castillo

SECTION 4

Procedures in the intensive cardiovascular care unit

20 Imaging- guided transseptal puncture and transcatheter closure of patent foramen ovale/ atrial septal defect, ventricular septal defect, and paravalvular leaks 287

Itzhak Kronzon, Juan Manuel Monteagudo, Francesco F. Faletra, Priti Mehla, and Muhamed Saric

21 Imaging for electrophysiological procedures 303

Louisa O’Neill, Iain Sim, John Whitaker, Steven Williams, Henry Chubb, Pál Maurovich-Horvat, Mark O’Neill, and Reza Razavi

22 Transcatheter aortic valve implantation 315

Arnold C.T. Ng, Victoria Delgado, and Jeroen J. Bax

23 Transcatheter mitral valve interventions 337

Nina C. Wunderlich, Robert J. Siegel, Ronak Rajani, and Nir Flint

24 Transcatheter tricuspid valve repair/ replacement 361

Rebecca T. Hahn

25 Transcatheter pulmonic valve replacement 377

Kuberan Pushparajah and Alessandra Frigiola

SECTION 5

Coronary artery disease

26 Echocardiography and detection of coronary artery disease 395

Thor Edvardsen, Marta Sitges, and Rosa Sicari

27 Nuclear cardiology and detection of coronary artery disease 403

Richard Underwood, James Stirrup, and Danilo Neglia

28 PET-CT and detection of coronary artery disease 421

Marcelo F. Di Carli

29 MDCT and detection of coronary artery disease 435

Stephan Achenbach and Pál Maurovich-Horvat

30 CMR and detection of coronary artery disease 447

Eike Nagel, Juerg Schwitter, and Sven Plein

31 Non-invasive Imaging of the vulnerable atherosclerotic plaque 467

Rong Bing, David E. Newby, Jagat Narula, and Marc R. Dweck

32 Imaging of microvascular disease 481

Paolo G. Camici and Ornella Rimoldi

SECTION 6

Heart failure

33 Evaluation of systolic LV function and LV mechanics 497

Rainer Hoffmann and Frank A. Flachskampf

34 Evaluation of left ventricular diastolic function 507

Bogdan A. Popescu, Carmen C. Beladan, and Maurizio Galderisi†

35 Imaging of the right heart 519

Lawrence Rudski, Petros Nihoyannopoulos, and Sarah Blissett

36 Assessment of viability 545

Luc A. Pierard, Paola Gargiulo, Pasquale Perrone-Filardi, Bernhard Gerber, and Joseph B. Selvanayagam

37 Imaging cardiac innervation 565

Albert Flotats and Ignasi Carrió

38 Cardiac resynchronization therapy: Selection of candidates 577

Victoria Delgado and Jens-Uwe Voigt

39 Cardiac resynchronization therapy: Optimization and follow-up 587

Marta Sitges and Erwan Donal

40 Echocardiography evaluation in extracorporeal support 599

Susanna Price and Alessia Gambaro

41 Cardiac imaging in cardio-oncology 613

Riccardo Asteggiano, Patrizio Lancellotti, Maurizio Galderisi†, Stephane Ederhy, and Marie Moonen

SECTION 7

Cardiomyopathies

42 Hypertrophic cardiomyopathy 629

Nuno Cardim, Alexandra Toste, and Robin Nijveldt

43 Infiltrative cardiomyopathy 645

Massimo Lombardi, Silvia Pica, Antonella Camporeale, Alessia Gimelli, and Dudley J. Pennell

44 Dilated cardiomyopathy 661

Upasana Tayal, Sanjay Prasad, Tjeerd Germans, and Albert C. van Rossum

45 Other genetic and acquired cardiomyopathies 681

Kristina Haugaa and Perry Elliott

SECTION 8

Peri-myocardial disease

46 Pericardial effusion and cardiac tamponade 697

Allan Klein, Bernard Cosyns, and Aldo L. Schenone

47 Constrictive pericarditis 707

Alida L.P. Caforio, Maurizio Galderisi†, Massimo Imazio, Renzo Marcolongo, Yehuda Adler, and Ciro Santoro

48 Myocarditis 715

Ali Yilmaz, Heiko Mahrholdt, and Udo Sechtem

49 Cardiac masses and tumours 731

Teresa López-Fernández and Peter Buser

SECTION 9

Aortic disease: aneurysm and dissection

50 The role of echocardiography 747

Arturo Evangelista and Gisela Teixidó-Turà

51 Aortic disease: Aneurysm and dissection—role of CMR 757

Jose F. Rodriguez-Palomares and Arturo Evangelista

52 Aortic disease: Aneurysm and dissection—role of MSCT 771

Rocío Hinojar and Raimund Erbel

SECTION 10

Adult congenital heart disease

53 The role of echocardiography in adult congenital heart disease 783

Lindsay A. Smith, Mark K. Friedberg, and Luc Mertens

54 The role of CMR and MSCT 809

Giovanni Di Salvo and Francesca R. Pluchinotta

Index 823

Symbols and abbreviations

z video

cross reference

9 additional online material

M website

AC arrhythmogenic cardiomyopathy/attenuation correction

AccT acceleration time

ACE angiotensin-converting enzyme

ACR American College of Radiology

ACS acute coronary syndromes

AF atrial fibrillation

åICD implantable cardioverter defibrillator

Ar atrial reverse velocity

AR aortic regurgitation

ARVC arrhythmogenic right ventricular cardiomyopathy

AS aortic stenosis

ASD atrial septal defect

ASE American Society of Echocardiography

ASO amplatzer septal occluder

AV aortic valve/atrial valve

AVA aortic valve area

AVS aortic valve stenosis

BAV bicuspid aortic valve

BMI body mass index

BNP B-type natriuretic peptide

BSA body surface area

CAC coronary artery calcium

CAD coronary artery disease

CAV cardiac allograft vasculopathy

CBF coronary blood flow

CCT cardiac computed tomography

CCTA coronary computed tomography angiography

CFR case fatality rate/coronary flow reserve

CHF congestive heart failure

CIED cardiac implantable electrical devices

CLT Classroom and Laboratory Training

CM contrast material

CMD coronary microvascular dysfunction

CMR cardiac magnetic resonance

CPT cold pressure testing

CRT cardiac resynchronization therapy

CSA cross-sectional area

CT computed tomography

CTA computed tomography angiography

CTCA computed tomography coronary angiography

CTP computed tomography myocardial perfusion

CW colour wave/continuous wave

CWD colour wave Doppler

CZT cadmium zinc telluride

DECT dual-energy computed tomography

DOPS Direct Observation of Practical Skills

DSCT dual-source computed tomography

DSE dobutamine stress echocardiography

EACTS European Association for Cardio-Thoracic Surgery

EACVI European Association of Cardiovascular Imaging

EAM electro-anatomical mapping

EANM European Association of Nuclear Medicine

EAPC European Association of Preventive Cardiology

ECMO extracorporeal membrane oxygenation

ECNC European Council of Nuclear Cardiology

ECV extracellular volume

ED effective radiation dose

ED external diameter

EDIC Echo Dobutamine International Cooperative

EDT E wave deceleration time

EDV end-diastolic volume

EF ejection fraction

EOA effective orifice area

EPIC Echo-Persantine International Cooperative

ERO effective regurgitant orifice

EROA effective regurgitant orifice area

ESC European Society of Cardiology

ESCR European Society of Cardiac Radiology

ESCR European Society of Cardiovascular Radiology

ESV end-systolic volume

EVEREST Endovascular Valve Edge-to-Edge REpair Study

FAC fractional area change

FBP filtered back-projection

FF forward flow

FFA free fatty acid

FFR fractional flow reserve

FO fossa ovalis

FOV field of view

FWLS free wall longitudinal strain

GCV GREAT cardiac vein

GLS global longitudinal left ventricular strain

GLS global longitudinal strain

HCM hypertrophic cardiomyopathy

HF heart failure

HFA Heart Failure Association

HFpEF heart failure with preserved ejection fraction

HLA horizontal long axis

HR heart rate

HU Hounsfield Units

HVD heart valve disease

IAEA International Atomic Energy Agency

ICA invasive coronary angiography

ICU intensive care unit

IDR iodine delivery rate

INCAPS IAEA Nuclear Cardiology Protocols Cross-Sectional Study

IOD internal orifice diameter

IRIS iterative reconstruction in image space

IVC inferior vena cava

IVRT isovolumic relaxation time

IVUS intravascular ultrasound

LA left atrium

LA long axis

LAA left atrial appendage

LAD left anterior descending

LAP left atrial pressure

LAV left atrial volume

LAVi LA volume indexed to body surface area

LBBB left bundle branch block

LD left disc

LDL low-density lipoprotein

LGE late gadolinium enhancement

LMV left marginal vein

LOR line-of response

LS longitudinal strain

LV left ventricle

LVAD left ventricular assistance device

LVFP left ventricular filling pressure

LVEDD left ventricle end-diastolic dimension

LVEDP left ventricular end-diastolic pressure

LVEF left ventricular ejection fraction

LVESV left ventricular end-systolic volume

LVOT left ventricular outflow tract

MACE major adverse cardiovascular events

MAD mitral annular disjunction

MAPSE mitral annular plane systolic excursion

MBF myocardial blood flow

MCE myocardial contrast echocardiography

MCQ multiple choice question

MDCT multidetector-row computed tomography

MESA Multi-Ethnic Study of Atherosclerosis

MFR myocardial flow reserve

MI mechanical index

MI myocardial infarction

MIP maximum intensity projections

MPI myocardial performance index/myocardial perfusion imaging

MPRI myocardial perfusion reserve index

MR mitral regurgitation

MRA magnetic resonance angiography

MRCA magnetic resonance coronary angiography

MRI magnetic resonance imaging

MS mitral stenosis

MV mitral valve

MVA mitral valve area

MVO microvascular obstruction

NASCI North American Society for Cardiovascular Imaging

NBE National Board of Echocardiography

NMR nuclear magnetic resonance

NYHA New York Heart Association

OCT optical coherence tomography

OR operating room

PA pulmonary artery

PAH pulmonary arterial hypertension

PAP pulmonary arterial pressure

PASP pulmonary artery systolic pressure

PCWP pulmonary capillary wedge pressure

PE pulmonary embolism

PET positron emission tomography

PFO patent foramen ovalis

PH pulmonary hypertension

PHT pressure half-time

PISA proximal isovelocity surface area

PIV posterior interventricular vein

PLARC paravalvular Leak Academic Research Consortium

PPL referred to as periprosthetic leak

PR pulmonary regurgitation

PS pulmonary stenosis

PSF point spread function

PSIR phase-sensitive inversion recovery

PSS post-systolic shortening

PV pulmonary valve

PVI pulmonary vein isolation

PVLV posterior vein of the left ventricle

PVR pulmonary vascular resistance

PW pulsed wave

QA quality assurance

RA right artery

RAP right atrial pressure

RCA right coronary artery

RD right disc

RF regurgitant flow

RF regurgitant fraction

RIMP right-sided index of myocardial performance

ROI region of interest

ROS reactive oxygen species

RPM revolutions per minute

RV right ventricle

RVAD right ventricular assist device

RVEF right ventricular ejection fraction

RVOT right ventricular outflow tract

RVSP right ventricular systolic pressure

SAM systolic anterior motion

SARF severe acute respiratory failure

SCCT Society of Cardiovascular Computed Tomography

SCD sudden cardiac death

SCMR Society for Cardiovascular Magnetic Resonance

SD standard deviation

SE stress echocardiography

SHD structural heart disease

SL septal leaflet

SNR signal-to-noise ratio

SPAMM spatial modulation of magnetization

SPECT single photon emission computed tomography

SRD sewing ring diameter

SSFP steady-state free precession

STE speckle tracking echocardiography

SV stroke volume

SVC superior vena cava

TA tricuspid annular

TAC time-activity curves

TAD tissue annulus diameter

TAPSE tricuspid annular plane systolic excursion

TAVI transcatheter aortic valve implantation

TAVR transcatheter aortic valve replacement

TOE transoesophageal echocardiography

TI the optimal inversion

TOF tetralogy of Fallot

TOF time of flight

TR tricuspid regurgitation

TTDE the feasibility of transthoracic doppler echocardiography

TV tricuspid valve

USPIO ultrasmall superparamagnetic iron oxide

VA ventricular arrhythmias

VAD ventricular assist device

VC vena contracta

VHD valvular heart disease

VLA vertical long axis

VSD ventricular septal defect

VT velocity time

VT ventricular tachycardia

VTI velocity-time integral

WISE Women’s Ischemia Syndrome Evaluation

Contributors

Stephan Achenbach

Department of Cardiology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany

Yehuda Adler

The Gertner Institute, Sheba Medical Center, affiliated to Sackler Medical School, Tel Aviv University and the College for Academic Studies, Tel Aviv, Israel

Riccardo Asteggiano, MD, FESC

Adjunct Professor, Faculty of Medicine, Insubria University, Varese, Italy; LARC (Laboratorio Analisi e Ricerca Clinica), Turin, Italy

Luigi P. Badano, MD, PhD, FESC, FACC, Honorary FASE, Honorary FEACVI

Professor of Cardiovascular Medicine, University of MilanoBicocca; Director of the Cardiovascular Imaging Unit, Department of Cardiovascular, Neural and Metabolic Sciences; Istituto Auxologico Italiano, IRCCS, Milano, Italy; Istituto Auxologico Italiano, IRCCS, Cardiology Unit, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, and Department of Medicine and Surgery, University of Milano-Bicocca, Piazzale Brescia, MI, Italy

Helmut Baumgartner, MD

Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany

Jeroen J. Bax, MD, PhD

Professor of Cardiology, Head Department of Non-invasive Imaging, Leiden University Medical Center, The Netherlands

Harald Becher, MD, PhD, FRCP

Professor of Medicine, ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Alberta, Canada

Carmen C. Beladan, MD, PhD

University of Medicine and Pharmacy ‘Carol Davila’— Euroecolab, Emergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’, Bucharest, Romania

Frank M. Bengel, MD, Univ. Prof. Dr. med. Director, Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany

Rong Bing , MBBS

Doctor, Department of Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK

Sarah Blissett, MD, MHPE

Cardiologist, London Health Sciences Centre, London, Canada; Assistant Professor (Medicine), Western University, London, Canada; Researcher, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Canada

Jan Bogaert, MD, PhD Faculty of Medicine, Department of Imaging and Pathology, University Hospitals Leuven, Leuven, Belgium

Eric Brochet Department of Cardiology, University Hospital Bichat, Paris, France

Peter Buser, MD Department of Cardiology, University Hospital Basel, Basel, Switzerland

Filippo Cademartiri, MD, PhD Chairman Prof. Dr., Department of Radiology, Area Vasta 1— ASUR Marche, Urbino, PU, Italy

Alida L.P. Caforio, MD, PhD, FESC Cardiologist, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy

Paolo G. Camici, MD, FESC, FAHA, FACC, FRCP Professor of Cardiology, Department of Cardiovascular Research Center, San Raffaele Hospital and Vita Salute University, Milan, Italy

Antonella Camporeale, MD, PhD Multimodality Cardiac Imaging Section, I.R.C.C:S., Policlinico San Donato, Milan, Italy

Nuno Cardim, MD, PhD

Head Echo Lab, Department of Cardiology, Hospital da Luz, Lisbon, Portugal

Ignasi Carrió, MD, FEBNM, FESC, FRCP

Professor of Nuclear Medicine, Universitat Autònoma de Barcelona, Director, Nuclear Medicine Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

Henry Chubb

Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, USA

Marie-Annick Clavel, DVM, PhD

Associate Professor, Department of Medicine, Laval University, Canada Research Chair on Women’s Valvular Heart Health, Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada

Bernard Cosyns , MD, PhD, FESC, FEACVI

Cardiology Department, Centrum voor hart en vaatziekten, Universitair ziekehuis Brussel, 101 laarbeeklaan 1090 Brussels, Belgium

Nancy Côté, PhD

Institut Universitaire de cardiologie te de Pneumologie de Québec, Québec, Canada

Álvaro Marco del Castillo, MD

Victoria Delgado, MD, PhD

Cardiologist, Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands

Marcelo F. Di Carli, MD

Executive Director, Cardiovascular Imaging, Department of Radiology and Medicine, Brigham and Women’s Hospital, Boston, MA, USA, and Family Professor of Radiology and Medicine, Women’s Hospital, Seltzer, Harvard Medical School, Boston, MA, USA

Giovanni Di Salvo, MD, PhD, MSc, FESC, FEACVI, FISC

Professor and Director, Department of Paediatric Cardiology and Congenital Heart Disease, University of Padua, Padua, Italy; Honorary Consultant Royal Brompton Hospital, London, UK

Erwan Donal, MD, PhD

Cardiology & INSERM1099, University Hospital, University Rennes-1, France

Sharmila Dorbala , MD

Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA

Marc R. Dweck , MD, PhD

Professor, Department of BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK

Stephane Ederhy

Department of Cardiology, AP-HP, Saint-Antoine Hospital, Sorbonne University, Paris, France

Thor Edvardsen, MD, PhD

Professor, Department of Cardiology, Oslo University Hospital, Oslo, Norway

Perry Elliott

Chair of Cardiovascular Medicine, University College London, London, UK

Raimund Erbel, MD, FAHA, FESC, FASE, FACC

Medical Informatics, Biometry and Epidemiology, University Clinic, Universitat Duisburg-Essen, Essen, Germany

Arturo Evangelista , MD, FESC

Institut de Recerca Vall d’Hebron (VHIR), Coordinator of Valvular and Aortic Research Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain

Francesco F. Faletra , MD

Director of Cardiac Imaging Service, Cardiocentro Ticino Lugano, Switzerland

Covadonga Fernández-Golf ín, MD

Cardiac Imaging Unit Coordinator, Cardiology Department, Ramón y Cajal University Hospital, Madrid, Spain

Frank A. Flachskampf, MD, FESC, FACC Professor, Department of Medical Sciences, Uppsala University, Uppsala, Sweden

Nir Flint, MD

Attending Cardiologist, Echocardiography Lab, Division of Cardiology, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Albert Flotats , MD

Consultant, Department of Nuclear Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

Kevin Fox , MD, FRCP, FESC

Consultant Cardiologist, Department of Cardiology, Imperial College Healthcare NHS Trust, London, Middlesex, UK

Mark K. Friedberg , MD Professor, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada

Alessandra Frigiola , MD, MD(res), FRCP

Consultant Cardiologist—ACHD specialist, Cardiovascular, ACHD, Guy’s & St Thomas’ Hospital, NHS Foundation Trust, London, UK

Maurizio Galderisi, MD† Professor of Medicine, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy

Alessia Gambaro, MD

Cardiology Division, Department of Medicine, University of Verona, Verona, Italy

Madalina Garbi, MD, MA

Consultant Cardiologist, Department of Cardiology, Royal Papworth Hospital, Cambridge, UK

Paola Gargiulo, MD, PhD

Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy

Bernhard Gerber, MD, PhD, FESC, FACC, FAHA

Professor of Medicine, Cardiology Division, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc UC Louvain, Brussels, Belgium

Tjeerd Germans , MD, PhD

Cardiologist, Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands

Silvia Gianstefani, MD

Alessia Gimelli, MD

Fondazione Toscana Gabriele Monasterio, Pisa, Italy

Andreas Hagendorff, MD

Professor, Department of Cardiology, University Hospital Leipzig, Leipzig, Germany

Rebecca T. Hahn, MD, FESC

Department of Medicine, Division of Cardiology/New York Presbyterian Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA

Kristina Haugaa, MD

Rocío Hinojar, MD

Ramón y Cajal University Hospital, Madrid, Spain

Rainer Hoffmann, MD

Professor, Department of Cardiology, Bonifatius Hospital Lingen, Lingen, Germany

Massimo Imazio, MD, FESC

Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, Milan, Italy

Jarosław D. Kasprzak , MD, PhD Professor of Medicine, Department and Chair of Cardiology, Bieganski Hospital, Medical University of Lodz, Lodz, Poland

Rajdeep S. Khattar, DM, FRCP, FACC, FESC

Consultant Cardiologist and Honorary Clinical Senior Lecturer, Royal Brompton and Harefield NHS Trust, and National Heart and Lung Institute, Imperial College, London, UK

Lars Gunnar Klaeboe

Allan Klein, MD, FRCP(C), FACC, FAHA, FASE

Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Director, Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA

Juhani Knuuti, MD, PhD, FESC

Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland

Itzhak Kronzon, MD, FASE, FESC, FACC, FAHA, FCCP

Professor of Cardiovascular Medicine, Hofstra University, NY, USA

Patrizio Lancellotti

Professor, Head of Department, Department of Cardiology, University of Liège Hospital, Liège, Belgium

Jonathan Leipsic, MD, FRCPC, MSCCT

Physician, Department of Imaging and Cardiology, UBC, Vancouver, BC, Canada

Riccardo Liga , MD, PhD

Cardiologist, Cardiothoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy

Massimo Lombardi, MD, FESC, PhD

Head, Multimodality Cardiac Imaging Section, I.R.C.C.S Policlinico San Donato, Milan, Italy

Teresa López-Fernández , MD

Senior Consultant Cardiologist, Department of Cardiology, La PAz University Hospital, IdiPAZ Research Institue, Ciber CV, Madrid, Spain

Joseph F. Maalouf, MD, FAHA, FACC, FASE Professor of Medicine, Director of Interventional Echocardiography, Consultant in Cardiovascular Diseases, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA

Julien Magne, PhD Department of Cardiology, CHU de Limoges, Limoges, France

Heiko Mahrholdt

Professor Doctor, Head of Imaging, Department of Cardiology, Robert Bosch Medical Center, Stuttgart, BW, Germany

Renzo Marcolongo, MD

Senior Staff Physician, Department of Medicine, Azienda Ospedale Università Padova, Padova, Italy

Pál Maurovich-Horvat, MD

Priti Mehla , MD

Lenox Hill Hospital, New York, NY, USA

Luc Mertens , MD, PhD Professor of Paediatrics, Department of Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada

Hector I. Michelena , MD, FACC, FASE, FESC Professor of Medicine, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA

James Min, MD

Mark J. Monaghan, PhD, FRCP (Hon), FACC, FESC Director of Non-Invasive Cardiology, King’s College Hospital, Denmark Hill, London, UK

Juan Manuel Monteagudo, MD

Department of Cardiology, University Hospital Ramón y Cajal, Madrid, Spain

Marie Moonen, MD, PhD

University Hospital Sart Tilman, GIGA Cardiovascular Sciences, Department of Cardiology, Liege, Belgium

Daniel Rodríguez Muñoz , MD, PhD

Consultant, Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain

Denisa Muraru, MD, PhD, FESC, FACC, FASE

Department of Medicine and Surgery, University of MilanoBicocca, Istituto Auxologico Italiano, IRCCS, Milan, Italy

Eike Nagel, MD

Jagat Narula , MD, PhD, MACC

Philip J. and Harriet L. Goodhart Chair of Medicine, Professor of Medicine, Radiology and Health System Design & Global Health, Chief, Division of Cardiology, Mount Sinai Hospital Morningside; Associate Dean for Global Health, Icahn School of Medicine at Mount Sinai, Executive Editor, Journal of the American College of Cardiology; Vice President Elect, World Heart Federation, New York, NY, USA

Danilo Neglia , MD

Fondazione Toscana G. Monasterio, Via G. Moruzzi, Pisa, Italy

Stephan G. Nekolla , PhD, FESC

Adjunct Teaching Professor, Nuklearmedizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, and Deutsches Zentrum für Herz-Kreislauf-Forschung

e.V. Partner site Munich Heart Alliance, München, Germany

David E. Newby

Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK

Arnold C.T. Ng

Princess Alexandra Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, South Western Sydney Clinical School, the University of New South Wales, Australia

Petros Nihoyannopoulos, MD

Robin Nijveldt, MD, PhD, FESC

Cardiologist, Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands

Louisa O’Neill

King’s College London, UK; Guy’s and St Thomas NHS Foundation Trust, London, UK

Mark O’Neill, MD

Stefan Orwat, MD

Consultant Cardiologist, Adult Congenital and Valvular Heart Disease Department, University of Muenster, Muenster, Germany

Dudley J. Pennell, MD, FRCP, FACC, FESC, FRCR, FAHA, FMedSci, FSCMR

National Heart and Lung Institute, Imperial College, Royal Brompton and Harefield NHS Foundation Trust, London, UK

Pasquale Perrone-Filardi

Department of Clinical Medicine, Cardiovascular and Immunology Sciences, Federico II University, Naples, Italy

Ferande Peters, MBBCH, FCP (SA), FACC, FESC, FRCP

Senior Cardiologist, Associate Professor, Flora Hospital, Cardiovascular Pathophysiology and Genomics Unit, University of the Witwatersrand, Johannesburg, South Africa

Philippe Pibarot, DVM, PhD, FESC, FACC, FAHA, FCCS

Head of Cardiology Research, Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec, QC, Canada

Silvia Pica , MD

Multimodality Cardiac Imaging Section, I.R.C.C:S., Policlinico San Donato, Milan, Italy

Luc A. Pierard, MD, PhD, FESC

Honorary Professor of Medicine, Department of Cardiology, University of Liège, Liège, Belgium

Fausto J. Pinto, MD, PhD, FESC, FACC, FASE, FSCAI

Head of Department, Department of Cardiovascular Medicine, University Hospital, Universidade de Lisboa, Lisbon, Portugal

Sven Plein, MD, PhD, FRCP

Professor, British Heart Foundation Professor of Cardiovascular Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK

Francesca R. Pluchinotta , MD

Consultant of Pediatric Cardiology and Adult Congenital Heart Disease, Multimodality Cardiac Imaging Unit, IRCCS Policlinico San Donato, Milan, Italy

Gianluca Pontone, MD, PhD

Director, Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy

Bogdan A. Popescu, MD, PhD, FESC, FACC

Professor of Cardiology, University of Medicine and Pharmacy ‘Carol Davila’—Euroecolab, Head of Cardiology Department, Emergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’, Bucharest, Romania

Sanjay Prasad, MD

Susanna Price, MD, PhD

Professor of Cardiology and Intensive Care, Adult Intensive Care Unit, Royal Brompton Hospital, London, UK

Kuberan Pushparajah, MD

Ronak Rajani, BM, DM, FRCP, FESC, FSCCT, FACC

Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Reza Razavi, MD

Ornella Rimoldi, MD

IBFM, Consiglio Nazionale delle Ricerche, Segrate, Italy

Jose F. Rodriguez-Palomares , MD, PhD

Director of Cardiovascular Imaging Department, Department of Cardiology, Vall Hebrón Hospital, Barcelona, Catalonia, Spain

Lawrence Rudski, MD, FRCPC

Director, Azrieli Heart Center, Jewish General Hospital, McGill University, Montreal, QC, Canada

Elif Leyla Sade, MD

Professor of Cardiology, Department of Cardiology, Baskent University, Ankara, Turkey

Ciro Santoro, MD

Department of Advanced Biomedical Science, Federico II, University Hospital, Naples, Italy

Antti Saraste, MD, PhD, FESC

Professor, Chief Cardiologist, Heart Center, Turku University Hospital, Turku, Finland

Muhamed Saric, MD, PhD

Director, Noninvasive Cardiology, Professor of Medicine, Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY

Aldo L. Schenone, MD

Chief Cardiovascular Imaging Fellow

Section of Non Invasive Cardiovascular Imaging, Department of Radiology

Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

Juerg Schwitter, MD

Full Professor, Cardiovascular Department, University Hospital Lausanne, CHUV, Faculty of Biology and Medicine, Lausanne University, Lausanne, VD, Switzerland

Udo Sechtem, MD

Associate Professor of Cardiology, Cardiologicum and RobertBosch-Krankenhaus, Stuttgart, Germany

Joseph B. Selvanayagam, MD, PhD

Professor in Cardiovascular Medicine, Flinders University, Adelaide, Australia

Roxy Senior, MD, DM, FRCP, FACC, FESC

Consultant Cardiologist and Professor of Cardiology, Department of Cardiology, Royal Brompton Hospital, London, UK

Rosa Sicari, MD, PhD

Research Director, Department of Biomedicine, Institute of Clinical Physiology, Pisa, PI, Italy

Robert J. Siegel, MD, FACC

Kennamer Chair in Cardiac Ultrasound, Medical Director, Clinic for Hypertrophic Cardiomyopathy and Aortopathies; Director, Cardiac Noninvasive Laboratory; Professor of Medicine, Cedars-Sinai Medical Center and UCLA School of Medicine, CA, USA

Iain Sim, MD

Clinical Research Fellow in Cardiology, King’s College London, UK

Marta Sitges , MD, PhD

Director, Cardiovascular Institute, Hospital Clinic, Professor of Medicine, University of Barcelona, Barcelona, Spain

Lindsay A. Smith

University Hospital Southampton, Southampton, UK

James Stirrup, DLM, MD(Res), FSCCT, FRCP

Consultant Cardiologist, Department of Cardiology, Royal Berkshire NHS Foundation Trust, London, UK

Stephan Stobe, MD

Rolf Symons , MD, PhD

Department of Imaging and Pathology, Faculty of Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium

Ewa Szymczyk, MD

Bhupendar Tayal, MD

Upasana Tayal, MD

Gisela Teixidó-Turà , MD, PhD, FESC

Vall d’Hebron Research Institute, Hospital Universitari Vall d’Hebron, CIBER-CV, Barcelona, Spain

Alexandra Toste, MD

Hospital da Luz, Inherited Cardiovascular Diseases & Hypertrophic Cardiomyopathy Center, Affiliated Professor at NOVA Medical School, Lisbon, Portugal

Richard Underwood, MA, DM, FRCP, FRCR Emeritus Professor of Cardiac Imaging, National Heart and Lung Institute, Imperial College London, London, UK

Philippe Unger, MD, PhD

Head of Department, Department of Cardiology, CHU SaintPierre, Université Libre de Bruxelles, Brussels, Belgium

Albert C. van Rossum, MD, PhD Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands

Jens-Uwe Voigt, MD, PhD, FESC

Head of Echocardiography, Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium

John Whitaker

Division of Imaging Sciences and Biomedical Engineering, King’s College, London, UK

Steven Williams

Division of Imaging Sciences and Biomedical Engineering, King’s College, London, UK

Jeremy Wright, MBBS, FRACP

Cardiologist, Greenslopes Private Hospital, Brisbane, Australia

Nina C. Wunderlich, MD

Head of Noninvasive Cardiology, Department of Cardiology, Cardiovascular Center Darmstadt, Darmstadt, Hessen, Germany

Kyriakos Yiangou, MD, MSc, FESC, FACC, FEACVI

Cardiologist, President Cyprus Society of Cardiology

Ali Yilmaz , MD

Department of Cardiology, Division of Cardiovascular Imaging, University Hospital Münster, Germany

José Luis Zamorano, MD, PhD

Head of Cardiology, University Hospital Ramon y Canal, Madrid, Spain

SECTION 1 Technical aspects of imaging

1 Conventional echocardiography—basic principles 3 Andreas Hagendorff, Stephan Stobe, and Bhupendar Tayal

2 Nuclear cardiology (PET and SPECT)—basic principles 41 Danilo Neglia, Riccardo Liga, Stephan G. Nekolla, Frank M. Bengel, Ornella Rimoldi, and Paolo G. Camici

3 Cardiac CT—basic principles 57 Gianluca Pontone and Filippo Cademartiri

4 CMR—basic principles 67

Jan Bogaert, Rolf Symons, and Jeremy Wright

5 Training and competence in cardiovascular imaging 79 Kevin Fox and Marcelo F. Di Carli

Contents

Introduction 3

Principles of transthoracic echocardiography—practical aspects 3

Principles of image optimization and identification of artefacts—practical aspects 7

Standardized data acquisition in transthoracic echocardiography 7

Principles of transoesophageal echocardiography—practical aspects 24

Standardized data acquisition in transoesophageal echocardiography 28

Standard values in transthoracic and transoesophageal echocardiography 37

M-mode measurements 37

Two-dimensional measurements 38

Pulsed spectral Doppler measurements 38

Continuous wave Doppler measurements 38

Pulsed spectral tissue Doppler measurements 38

Acknowledgements 40

CHAPTER 1 Conventional echocardiography—basic principles

Introduction

Echocardiography is an imaging technique that enables accurate assessment of cardiac structures and cardiac function. Conventional echocardiography involves different modalities—especially the M-mode, the 2D, and colour Doppler, as well as the pulsedwave and continuous wave Doppler. The M-mode illustrates the reflections of a single sound beam plotted against time. 2D echocardiography enables the documentation of views, which represent characteristic sectional planes of the moving heart during one heart cycle. Colour Doppler echocardiography adds the information of blood flow to the 2D cineloop. Pulsed-wave Doppler is the acquisition of a local blood flow spectrum of a defined region represented by the dimension of the sample volume, whereas continuous wave Doppler displays the blood flow spectrum of all measured blood flow velocities along a straight line sound beam from its beginning to the end. The handling of the transducer has to be target-oriented, stable with respect to the imaging targets, and coordinated with respect to angle differences between the defined views to use all these modalities correctly to get optimal image quality of the cineloops and spectra.

Thus, the focus of this chapter will be a mainly practically oriented description of scanning technique in transthoracic and transoesophageal echocardiography.

The echocardiographic documentation requires image optimization and ultrasound machines, which fulfil the international laboratory standards in echocardiography. Thus, the equipment has to be minimally capable to enable broadband 2D imaging, M-mode imaging, pulsed and continuous wave Doppler, as well as colour-coded imaging, pulsed tissue Doppler imaging, and complete digital storage capability. In addition, the ultrasound system has to have all technical possibilities for transoesophageal, contrast, and stress echocardiography. An electrocardiographic (ECG) recording should generally be performed in order to be able to capture complete heart cycles according to the ECG trigger. This chapter is written in accordance with the current international guidelines and recommendations [1–7].

Principles of transthoracic echocardiography— practical aspects

The main principle of echocardiographic scanning is an exact or best possible manual control of the region of interest during the technical procedure. This principle includes the ability to move a certain cardiac structure within the scan sector from the left to the right and vice versa without losing the cardiac structures of the selected sectional

plane. In addition, this aspect is documented by the ability to rotate the transducer exactly about 60 or 90° without losing the defined cardiac structure in the centre of the primary scan sector before rotating. In other words, the visualization of cardiac structures in the centre of the scan sector has to be combined with the technical skill of the investigator to change only one plane within the spatial coordinates to achieve accurate characterization and documentation of the target cardiac structure. Thus, the easy message of transthoracic echocardiography is scanning by tilting without flipping and rotating, by flipping without tilting and rotating, as well as by rotating without tilting and flipping. This sounds easy, but it requires a stable transducer position next to the skin of the patient, an absolutely stable guiding of the transducer, and a stereotactic manual control of the transducer.

Regarding these aspects it is surprising that the finger position of holding a transducer has almost never been described in lectures and books about echocardiography, whereas in every book about musical instruments instructions of hand and finger positions, and illustrations of fingering charts are given.

In transthoracic echocardiography there is a complex interaction between the eyes, the brain, and the hand muscles to coordinate looking to a monitor to detect incongruities between the actual view and defined views and to correct them by manual manoeuvres to get the standardized views. Thus, it is like ‘seeing’ the heart with your hands. A basic position of the transducer in the hand is necessary to get the orientation for the scan procedure for an easy, but controlled change of a sectional plane. This implies that a defined holding of the transducer is always linked to a

defined hand position which has to be linked with a defined view. In echocardiography in adult patients, the echocardiographic investigation normally starts with the left parasternal approach. It is obvious that the basic holding of the transducer should be linked to the long-axis view of the left ventricle. In consequence, all possible long-axis views that can be acquired between the position of the left parasternal and the apical approach should be linked to this defined hand-holding of the transducer. If you change your basic position of holding the transducer during the scanning procedure of the same sectional plane, the imagination and association of the individual coordinates of the heart within the thorax will be lost by the investigator, which means that he will become disoriented or blind during scanning.

It has to be mentioned and emphasized, that scanning is possible with the right as well as with the left hand. The argument for a correct scanning technique is always the acquisition of standardized images with high image quality. Thus, echocardiographic scanning can be performed as the investigator is, or has been, taught how to do it. The author of this chapter, however, scans with the right hand. Thus, the images of how to hold the transducer and adjust the finger positions are shown for right-hand scanners.

To get a stable position for the transducer holding, all fingers are generally lifted and not extended. The pulps of the fourth and fifth fingers conveniently lie on the small edge of the transducer without any muscle tension (E Fig. 1.1a). The pulp of the thumb is conveniently placed on the notch of the transducer without any muscle tension (E Fig. 1.1b). This convenient relaxed transducer holding has to be conceptionally combined with

Fig. 1.1 Correct relaxed holding of the transducer using the right hand. The transducer lies on the fourth and fifth finger without any muscle tension (a), the pulp of the thumb only has contact to the notch of the transducer (b). The pulps of the fourth and fifth finger have contact to the skin (c) and the feeling of this transducer holding is combined with the parasternal log axis view (d).

Fig. 1.2 Examples of inconveniently holding the transducer. In (a) the fourth and fifth finger are between the transducer and the skin like writing with a pencil. No stable contact to the skin results in non-stabilization of the transducer. In (b) the holding is like encompassing a horizontal bar. Thus, rotation of the transducer is not performed by the hand—it has to be done by the shoulder and/or cubital joint. In (c) the thumb is too extended and the pulp of the thumb is not at the notch causing a blind feeling when moving or rotating the transducer. In addition, the mistake in Fig. 1.2a is also seen. In (d) no finger has contact to the skin. Thus, every trembling of the hand is bridged to the transducer and consequently to the images on the monitor. It is also not possible to get a basis for a defined flipping, tilting, and rotation, because the starting position is not stable.

the basic position of the transducer in the parasternal long-axis view of the heart (E Fig. 1.1c, d). The loss of the feeling for the notch and extended or tensed fingers in the starting position will induce discomfort and restrict the degrees of freedom for the movement of the transducer. Thus, wrong transducer holdings (E Fig. 1.2a–d) will lead to disorientation and difficulties in fine-tuning for adjusting correct standardized views. An often observed mistake is not to fix the fourth and fifth finger on the skin of the patient, leading to an unstable transducer position. With tilting over the small edge using the transducer holding of this starting position in the long-axis view, the mitral valve, for example, can be moved from the right to the left and vice versa without losing the long-axis view.

A clockwise rotation of the transducer from the starting position is easy (E Fig. 1.3a), because there is free space to turn the thumb clockwise by bending backwards the fourth and fifth fingers ( E Fig. 1.3b, c). A 90° rotation is easily possible and thus, you will get the feeling of rotating exactly 90° clockwise at the left parasternal window to visualize a correct short-axis view (E Fig. 1.3d).

After acquisition of the necessary parasternal short-axis views the transducer is rotated counterclockwise back to the correct long-axis view. The correct position of the apical window and the correct apical long-axis view can be achieved by sliding down from the parasternal window to the apex without losing

the sectional plane of the long-axis view (E Fig. 1.4). At the end of this movement the right hand can support itself against the thorax with the complete auricular finger (E Figs. 1.5a, b). Fingers placed between the transducer and the thorax in this position will disturb or inhibit the correct documentation of apical standard views by positioning the transducer too perpendicular to the body surface inducing a right twisted position of the heart within the scan sector and/or foreshortening views. Without tilting and flipping the correct apical long-axis view, a clockwise rotation of exactly 60° can be performed (E Fig. 1.5c) to visualize a correct 2-chamber view (E Fig. 1.5d).

Combining a defined transducer holding always with the longaxis view and getting the stable feeling for this combination are the prerequisites for target-controlled scanning and the accurate assessment of cardiac structures. It is obvious that minimal manipulations of the transducer position can be easily performed and stably fixed using the correct scanning technique. Thus, a correct scanning technique is the prerequisite for images with at least best possible image quality.

The aim of a sufficient transthoracic, and also transoesophageal, echocardiographic investigation should be an almost reproducible standardized documentation, which enables an accurate diagnostic analysis for correct decision-making. A standardization of the documentation enables a comparison between current and previous findings to detect changes, improvements, or

Turn static files into dynamic content formats.

Create a flipbook