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Mayo Clinic
Rochester, Minnesota
Thomas R. Kimball, MD
Professor of Pediatrics
University of Cincinnati College of Medicine
Medical Director, Heart Institute
Cincinnati Children’s Hospital
Cincinnati, Ohio
John P. Kovalchin, MD
Director of Echocardiography
Director of Advanced Noninvasive Cardiac Imaging Fellowship
The Heart Center
Nationwide Children’s Hospital
Professor of Pediatrics
The Ohio State University
Columbus, Ohio
Robert Lichtenberg, MD
Heart Care Centers of Illinois
Berwyn, Illinois
Joseph Mahgerefteh, MD
Pediatric Cardiology Division
The Children’s Hospital at Montefiore
Albert Einstein College of Medicine
New York, New York
Joseph J. Maleszewski, MD
Associate Professor of Pathology and Medicine
College of Medicine
Consultant, Divisions of Anatomic Pathology and Cardiovascular Diseases
Mayo Clinic
Rochester, Minnesota
Shaji C. Menon, MD
Assistant Professor of Pediatrics
Adjunct Assistant Professor of Radiology
Department of Pediatric Cardiology
University of Utah
Salt Lake City, Utah
Erik C. Michelfelder, MD
Director, Fetal Heart Program
Co-Director, Cardiac Imaging
The Heart Institute
Cincinnati Children’s Hospital Medical Center
Professor of Pediatrics
University of Cincinnati College of Medicine
Cincinnati, Ohio
Fletcher A. Miller, Jr., MD, FASE, FACC, FAHA
Professor of Medicine
Mayo Clinic College of Medicine
Consultant
Division of Cardiovascular Diseases
Mayo Clinic
Rochester, Minnesota
L. LuAnn Minich, MD
Professor of Pediatrics
Division of Pediatric Cardiology
University of Utah
Salt Lake City, Utah
Jae K. Oh, MD
Professor of Medicine
Division of Cardiovascular Diseases
Mayo Clinic
Rochester, Minnesota
Ricardo H. Pignatelli, MD
Assistant Professor of Pediatrics
Texas Children’s Hospital
Baylor College of Medicine
Houston, Texas
Joseph T. Poterucha, DO
Assistant Professor of Pediatrics
Division of Pediatric Cardiology
Mayo Clinic College of Medicine
Rochester, Minnesota
Nathaniel W. Taggart, MD
Assistant Professor of Pediatrics
Mayo Clinic College of Medicine
Consultant, Division of Pediatric Cardiology
Department of Pediatric and Adolescent Medicine
Mayo Clinic
Rochester, Minnesota
Lloyd Y. Tani, MD
Professor of Pediatrics
Division Chief, Pediatric Cardiology
University of Utah School of Medicine
Co-Director, Heart Center
Primary Children’s Medical Center
Salt Lake City, Utah
Dongngan T. Truong, MD
Pediatric Cardiology Fellow
Department of Pediatrics
University of Utah
Salt Lake City, Utah
Himesh V. Vyas, MD
University of Florida
Gainesville, Florida
Luciana T. Young, MD
Associate Professor
Department of Pediatrics
Northwestern University Feinberg School of Medicine
Director, Echocardiography Laboratory
Ann & Robert H. Lurie Children’s Hospital of Chicago
Chicago, Illinois
15 Tetralogy of Fallot
Himesh Vyas, Jennifer Johnson and Benjamin W. Eidem
18 Truncus Arteriosus
Bernadette Richards, Frederick D. Jones, and John P. Kovalchin
22 Hypertrophic Cardiomyopathy
Patrick W. O’Leary
23 Additional Cardiomyopathies
Colin J. McMahon and Ricardo H. Pignatelli
24 Pericardial Disorders
Martha Grogan and Jae K. Oh
25 Systemic Diseases
Muhammad Yasir Qureshi and Steven E. Lipshultz
26 Vascular Abnormalities
Michele A. Frommelt and Peter C. Frommelt
27 Cardiac Tumors
Joseph J. Maleszewski and Frank Cetta
29 Pulmonary Hypertension
Peter Bartz and Stuart Berger
32 Fetal Echocardiography
John M. Simpson and Lindsey E. Hunter
34 Stress Echocardiography
Thomas R. Kimball
42 Eisenmenger Syndrome
Robert C. Lichtenberg and Frank Cetta
chocardiography has revolutionized the diagnostic approach to patients
E with congenital heart disease. A comprehensive cardiovascular ultrasound
imaging and hemodynamic evaluation is the initial diagnostic test used in the
assessment of any congenital cardiac malformation. Since echocardiography
became a part of clinical practice in the 1970s, the technology used for
cardiac imaging has been in a nearly constant state of change. New
techniques have been introduced at an increasingly rapid pace, especially
since the 1990s. In this chapter, we will review the basic physical properties
of ultrasound and the primary modalities used in clinical imaging. These
discussions will provide an important foundation that will allow us to
understand the more advanced methods of imaging and functional
assessment, which will be covered in more detail later.
WHAT IS ULTRASOUND?
Diagnostic ultrasound generates images of internal organs by reflecting sound
energy off the anatomic structures being studied. An ultrasound imaging
system is designed to project sound waves into a patient and detect the
reflected energy, then converting that energy into an image on a video screen.
The types of sound waves used are given the name “ultrasound” because the
frequencies involved are greater than the frequencies of sound that can be
detected by the human ear. The average human ear can respond to
frequencies between 20 and 20,000 Hz. Therefore, it stands to reason that
ultrasound waves have frequencies greater than 20,000 Hz. In clinical
practice, most imaging applications actually require frequencies in excess of
1 MHz. Current cardiac imaging systems have the ability to produce
ultrasound beams varying between 2 and 12 MHz. A typical diagnostic
ultrasound system consists of a central processing unit (CPU), the video
image display screen, a hard drive for storage of the digital images, and a
selection of transducers. The transducers both transmit and receive ultrasound
energy.
Some Definitions
Figure 1.1. Graphic depiction of a sound wave. The portions of the wave above the
dashed baseline represent compression of the medium by the energy in the wave.
Conversely, the portions of the wave shown below the baseline represent rarefaction. The
portion of the wave that lies between one peak and the next, or one valley and the next, is
referred to as the period. Wavelength is the distance covered by one period. Amplitude (A)
refers to the maximum change from baseline caused by the wave (by either compression or
rarefaction).
IMAGE GENERATION
Diagnostic ultrasound imaging relies on the ability of high-frequency sound
waves to propagate (travel) through the body and be partially reflected back
toward the sound source by target tissues within the patient (Fig. 1.2). The
imaging system generates the imaging beam by electrically exciting a number
of piezoelectric crystals contained within a transducer. The imaging beam is
then focused and projected into the patient. As the ultrasound beam travels
through the patient, some of the energy will be scattered into the surrounding
tissue (attenuation), and some will be reflected back toward the source by the
structures in the beam’s path. These reflected waves will provide the
information used to create images of the internal organs. This is the same
imaging strategy used in sonar technology to detect objects below the water’s
surface. The intensity (amplitude) of the reflected energy wave is
proportional to the density of the reflecting tissue (see later). The reflected
ultrasound energy induces vibrations in the transducer crystals and an electric
current is created. This current is sensed by the CPU and converted into a
video image.
The ultrasound image generation is based primarily on the amount of
energy contained in the reflected wave and the time between transmission of
the ultrasound pulse and detection of the reflected waves by the transducer
crystals. The interval between transmission and detection of the reflected
waves is referred to as “time of flight.” The depth at which the ultrasound
image is displayed is determined by this time interval. Reflections from
structures in the far field take longer to return to the transducer than do
reflections from objects close to the sound source. This time interval is
sensed by the CPU and directly converted into distance from the sound
source based on the speed of ultrasound propagation within tissue.
The energy contained within the reflected waves is related to the
amplitude of those waves. The amplitude of the reflected waves can be
measured based on the amount of electric current produced by the receiving
crystals. The brightness of the image created by the ultrasound system is
determined by the amplitude of the reflected waves. Bodily fluids, such as
blood, effusions, and ascites, will transmit nearly all of the energy contained
within the imaging beam. Because there is little reflected energy, these areas
are displayed as black (or nearly black) on the imaging screen. Air is not
dense enough to allow transmission of sound frequencies in the ultrasound
range. Therefore, all of the imaging energy present in the beam will be
reflected at an air–tissue interface, such as at the edge of a pneumothorax or
of the normal lung. This nearly 100% reflection is translated into a very
bright (usually white) representation on the imaging screen. Other very dense
tissues, like bone, will also reflect virtually all of the energy and be displayed
as very bright echo returns. Structures beyond these very bright “echoes”
cannot be displayed, because no ultrasound energy reaches them. These areas
are often referred to as acoustic shadows. Fat, muscle, and other tissues will
transmit some of the imaging beam and reflect a fraction of the sound wave.
The amount reflected is related to the density of the tissue, and the amount of
returning energy sensed by the crystals in the transducer will determine how
brightly an image will be displayed on the video screen.
Language: English
AN ANTHOLOGY SELECTED BY
FLORENCE B. HYETT
Anonymous
THE LAMB CHILD
TAR high
Baby low:
’Twixt the two
Wise men go;
Find the baby,
Grasp the star—
Heirs of all things
Near and far!
George Macdonald
THE CHRISTMAS CHILD
George Macdonald
THE LAMB
William Blake
SONG
Eugene Field
THE HOLLY
He has beamed all the year, but bright scarlet he’ll glow
When the ground glitters white with the fresh fallen snow.
Edith King
CAROL
William Canton
SHEPHERD’S SONG
Old Song