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This book is a step-by-step manual for the complete echo-novice. It should be the only book needed to become a proficient echocardiographer. The text focuses on the practicalities of performing an examination, and the interpretation of images. Avoiding unnecessary technicalities, it places particular emphasis on the diagnostic features of sample cases and covers the entire breadth of adult cardiology. The majority of the echo images are also available in a dynamic form on the Expert Consult platform. Also included is access to 100 case scenarios and images for self-assessment interpretation. The combination of the book and the website materials provides an unparalleled learning experience for people who do not routinely practise echocardiography.


  • The text covers the basic concepts of how ultrasound works and looks at practical aspects of how to perform an echo.
  • It examines both normal function as well as the whole range of pathologies encountered in day-to-day clinical practice.
  • There is particular emphasis on how to report your interpretation of the echo findings.
  • The book is highly illustrated throughout with real examples many of which are available to view in dynamic form on the Expert Consult platform, thus offering a comprehensive library of echo movies.
  • The text is fully up to date with the latest recommendations of the American Society of Echocardiography as well as equivalents from the British Society of Echocardiography
  • 100 self-assessment cases on the Expert Consult platform test knowledge and interpretation skills and are aimed at BSE accreditation exam level
  • The full text of the book is available on the Expert Consult platform
  • There are new chapters on 3D echo and right ventricular pathologies.
  • The text has been fully updated and there are more than 200 new images to illustrate state-of-the-art echo.
  • The presentation of the echo images has been simplified with the addition of a fold-out flap on the book referencing the key areas of anatomical detail.
  • The text now includes the latest recommendations of the American Society of Echocardiography as well as the equivalents from the British Society of Echocardiography


Derecho de autor
Reino Unido
Chronic obstructive pulmonary disease
Cardiac dysrhythmia
Atrial fibrillation
Myocardial infarction
Diastolic heart failure
Pharmaceutical formulation
Atrial myxoma
Mitral valve replacement
Ventricular pressure
Health care provider
Right ventricular hypertrophy
Bovine serum albumin
Pulmonary valve stenosis
Pericardial effusion
Magnetic resonance cholangiopancreatography
Valvular heart disease
Cardiac cycle
Cardiogenic shock
Blood culture
Left ventricular hypertrophy
Aortic valve replacement
Coarctation of the aorta
Mitral regurgitation
Ventricular septal defect
Thoracic aortic aneurysm
Body surface area
Pulmonary hypertension
Atrial septal defect
Aortic insufficiency
Mitral stenosis
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Arrhythmogenic right ventricular dysplasia
Blood flow
Patent ductus arteriosus
Infective endocarditis
Mitral valve prolapse
Renal cell carcinoma
Cor pulmonale
Congenital disorder
Heart rate
Aortic dissection
Cardiac tamponade
Tetralogy of Fallot
Mitral valve
Heart valve
Pulmonary embolism
Aortic valve stenosis
U.S. Patients' Bill of Rights
Jet aircraft
Medical ultrasonography
Power tool
Staphylococcus aureus
Heart disease
X-ray computed tomography
United Kingdom
Data storage device
Rheumatoid arthritis
Magnetic resonance imaging
Hypertension artérielle
Staphylocoque doré
Hypotension artérielle


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Published 02 April 2013
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EAN13 9780702045547
Language English
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E s s e n t i a l
E c h o c a r d i o g r a p h y
Alisdair Ryding, BSc(Med Sci) Hons, MBChB(Hons),
Consultant Cardiologist, Norfolk and Norwich University Hospital; Honorary Consultant
Cardiologist, James Paget University Hospital, Norwich, UKTable of Contents
Cover image
Title page
Section A: Getting started
Chapter 1: What is echocardiography?
Basic principles
Echocardiographic modes
Chapter 2: Views of the heart
The anatomy of the heart
Standard echocardiographic windows
Positioning yourself and holding the probe
Standard views
Putting it all together
Chapter 3: Optimising the picture
Patient optimisation
Examination environmentEcho optimisation
Section B: The cardiac chambers
Chapter 4: The left ventricle
The anatomy of the left ventricle
Left ventricular structure
Left ventricular mass
Left ventricular hypertrophy
Left ventricular systolic function
Chapter 5: Diastolic function and dyssynchrony
Left ventricular diastolic function
Diastolic dysfunction
Pulse wave Doppler assessment of diastolic function
Classifying diastolic function
Ventricular synchrony
Echocardiographic assessment of ventricular dyssynchony
Chapter 6: The right ventricle
The anatomy of the right ventricle
Assessing the right ventricle
Chapter 7: The atria
Anatomy of the atria
Normal variants
Atrial diseases
Chapter 8: Myocardial infarction
Acute complications
Chronic complications
Chapter 9: The cardiomyopathiesHypertrophic cardiomyopathy
Dilated cardiomyopathy
Restrictive cardiomyopathy
Chapter 10: Right ventricular pathologies
Right ventricular myocardial infarction
Arrhythmogenic right ventricular dysplasia (ARVD)
Cor pulmonale
Section C: The valves
Chapter 11: Principles of valve disease
Estimating pressure gradients: the Bernoulli equation
Measuring volumes and flow
Chapter 12: The aortic valve
The normal aortic valve
Aortic valve sclerosis
Aortic valve stenosis
Aortic valve regurgitation
Congenital abnormalities
Chapter 13: The mitral valve
The normal mitral valve
Diseases of the mitral valve
Assessing severity of mitral regurgitation
Mitral stenosis
Chapter 14: The right heart valves
The normal tricuspid and pulmonary valves
Tricuspid regurgitation
Tricuspid stenosisPulmonary stenosis
Pulmonary regurgitation
Diseases of the right heart valves
Pulmonary artery systolic pressure
Pulmonary artery diastolic pressure
Chapter 15: Infective endocarditis
Detection of a predisposing condition
Chapter 16: Prosthetic valves
Types of prosthetic valve
Normal function
Abnormal prosthetic valve function
Percutaneous valve treatments
Section D: Inside and outside the heart
Chapter 17: Pericardial disease
Pericarditis, pericardial effusion and tamponade
Constrictive pericarditis
Pericardial tumours
Chapter 18: Cardiac masses
Primary neoplasms
Secondary neoplasms
Intravascular devices
Normal variants and artefactChapter 19: The aorta
Diseases of the aorta
Congenital aortic disease
Chapter 20: Congenital septal abnormalities
Atrial septal defects
Ventricular septal defects
Quantitative assessment of intracardiac shunts
Percutaneous device closure
Chapter 21: 3D echocardiography
Principles of 3D echo
Imaging protocol
Clinical applications
Future directions
Section E: Approach to examining and reporting
Chapter 22: The comprehensive examination
Integrating information
The echo examination
Chapter 23: The focused examination
Cardiac arrest (pulseless electrical activity)
Acute chest pain
Acute breathlessness
Ventricular arrhythmia
Systemic embolismBlunt trauma
Chapter 24: Reporting an echo study
Figure labels
Section F: Appendices
Appendix 1: Normal values
Appendix 2: Useful formulae
IndexD e d i c a t i o n
For Christine, Grace, Eleanor, Beatrix and my parentsCopyright
© 2013 Elsevier Ltd All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission in writing from the
publisher. Details on how to seek permission, further information about the
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This book and the individual contributions contained in it are protected under
copyright by the publisher (other than as may be noted herein).
First edition 2008
Second edition 2013
ISBN 9780702045523
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should
be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised
to check the most current information provided (i) on procedures featured or (ii) by
the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safetyprecautions.
To the fullest extent of the law, neither the publisher nor the authors, contributors,
or editors assume any liability for any injury and/or damage to persons or property
as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material
Printed in China

Echocardiography is an immensely powerful tool, providing a wealth of information
about cardiac structure and function. Unlike other imaging modalities this can be
achieved painlessly, quickly, safely and at low cost. Echo machines are increasingly
portable, and easily used in a wide range of emergency and community se ings. N o
wonder there is huge interest and demand for training in echo by a wide spectrum of
healthcare providers.
Echocardiography is a daunting skill to learn, and there are many potential pitfalls
for the unsuspecting. How do you get good pictures? How do you distinguish normal
and abnormal? A re you making the right measurements and have you made the
correct diagnosis? Essential Echocardiography was wri en to provide answers to these
questions. I t is a practical guide that allows the beginner to become a confident and
independent practitioner. The first chapters cover the principles of ultrasound and
focus on the practical aspects of performing and optimising an echo. S ubsequent
chapters systematically look at the various cardiac chambers, valves and extra-cardiac
structures in health and disease. There are new chapters on 3D echo and right
ventricular pathologies, with more than 200 new images to illustrate state-of-the-art
Particular emphasis has been placed on the knowledge and skills required for
image interpretation, reporting and diagnosis: there are over 300 on-line videos to
allow you to develop this expertise. Finally I have wri en 100 on-line interactive
selfassessment questions to test your knowledge, understanding and diagnostic skills.
Alisdair Ryding, Norwich, UKAcknowledgements
I am very grateful to my patients, without whom this book would not exist. I am also
indebted to my colleagues, particularly:
Second edition
D r Heeraj Bullock, Mrs S arah Butcher, Mrs Karen Clifton, Mr Charles Graham, D r
Cairistine Grahame-Clarke, D r S imon Hansom, Mr D arren Hardy-S hepherd, Miss
Emma Lakey, Miss A ngela Merrick, Mrs Ruth Mixer, D r J N ewton, D r Helen
Oxenham, Miss S am Peck, Miss Hayley Reeve, Miss N atalie S ales, Mr S eamus Walker,
Mrs Sheila Wood.
First edition
D r K A srress, Prof H Becher, D r S Hussain, D r P Leeson, D r A Mitchell, D r J N ewton,
Mrs M Priest, Mrs S Ramsay, D r N S abharwal, Mrs D S mith, D r D S prigings, Mr D
Tetley, Dr J Timperley, Dr D Tomlinson, Prof S Westaby, Dr A Wrigley.
I would also like to thank everyone at Elsevier who has helped to make this book a
reality, in particular Laurence Hunter and Helen Leng.
Alisdair Ryding, Norwich, UKA b b r e v i a t i o n s
2 D two-dimensional
3 D three-dimensional
A transmitral Doppler atrial diastolic wave
a ' annular late diastolic myocardial velocity
A 2 C apical two-chamber
A 3 C apical three-chamber
A 4 C apical four-chamber
A 5 C apical five-chamber
A R atrial regurgitation
A R V D arrhythmogenic right ventricular dysplasia
A S A atrial septal aneurysm
A S D atrial septal defect
A S H asymmetric septal hypertrophy
A V atrioventricular/aortic valve
B A R T blue away, red towards
b p m beats per minute
B S A body surface area
C F M colour flow mapping
C O P D chronic obstructive pulmonary disease
C R T cardiac resynchronisation therapy
C T computed tomography
C W continuous wave (Doppler)
D S E dobutamine stress echo
D T deceleration time
D T I Doppler tissue imaging
E transmitral Doppler early diastolic wave
E : A ratio of E and A wave peak velocitiese ' annular early diastolic myocardial velocity
E C G electrocardiograph
E F ejection fraction
E R O A effective regurgitant orifice area
F S fractional shortening
H C M hypertrophic cardiomyopathy
H I V human immunodeficiency virus
H O C M hypertrophic obstructive cardiomyopathy
I A S interatrial septum
I E infective endocarditis
I V C inferior vena cava
I V S interventricular septum
I V S d diastolic interventricular septal thickness
L A left atrium
L B B B left bundle branch block
L G C lateral gain compensation
L V left ventricle
L V H left ventricular hypertrophy
L V I D left ventricular internal diameter
L V I D d end diastolic left ventricular internal diameter
L V I D s systolic left ventricular internal diameter
L V N C left ventricular non-compaction
L V O T left ventricular outflow tract
L V O T O left ventricular cardiomyopathy obstruction
M A P S E mitral annular plane systolic excursion
M I myocardial infarction
M R I magnetic resonance imaging
M V mitral valve
M V A mitral valve area
M V P mitral valve prolapse
P A S P pulmonary artery systolic pressure
P F O patent foramen ovale
P I S A proximal isovelocity surface area
P R F pulse repetition frequencyP S L A X parasternal long axis
P S S A X parasternal short axis
P V pulmonary valve
P W pulse wave (Doppler)
P W T posterior wall thickness
P W T d diastolic posterior wall thickness
R A right atrium
R M V D rheumatic mitral valve disease
R V right ventricle
R V E D P right ventricular end diastolic pressure
R V O T right ventricular outflow tract
R V S P right ventricular systolic pressure
R W M A regional wall motion abnormality
S A M systolic anterior motion of the mitral valve
S B P systolic blood pressure
S L E systemic lupus erythematosus
S V stroke volume
T A P S E tricuspid annular plane systolic excursion
T G C time gain compensation
T H I tissue harmonic imaging
T O E transoesophageal echocardiography
T T E transthoracic echocardiography
V S D ventricular septal defect
V T I velocity time integral
W M S I wall motion score indexS E C T I ON A
Getting started
Chapter 1: What is echocardiography?
Chapter 2: Views of the heart
Chapter 3: Optimising the pictureC H A P T E R 1
What is echocardiography?
Basic principles
Echocardiographic modes
Two-dimensional imaging
Three-dimensional imaging
M-mode imaging
Doppler ultrasound
Echocardiography is the use of specialised ultrasound equipment to image the structure and
function of the heart. I t is rather like sonar, in that sound waves are used to locate the position of
an object based on the characteristics of the reflected signal, hence the use of the term ‘echo’.
I t is not necessary to have a detailed knowledge of the physics of ultrasound or the inner
workings of an echo machine to be able to use one. However, to obtain the best information it is
useful to have a basic idea of the principles and limitations of the technique.
Basic principles
Ultrasound uses very-high-frequency sound waves (typically >1.5 MHz) that are beyond the
normal range of hearing (>20 kHz). A n echo transducer contains piezoelectric crystals (a ceramic
material) that vibrate at high frequency when an electric current is passed through them. They
convert electrical energy to ultrasound waves, and ultrasound back to electrical energy. I t is
therefore able to perform the dual role of emitting and transducing ultrasound.
The basic physical properties of ultrasound waves are the wavelength (λ, distance between
equivalent points in adjacent cycles; Fig. 1.1), frequency ( f, cycles per second) and velocity ( v,
direction and speed of travel). The relationship between these factors is described by the
equation: v = f λ.
FIGURE 1.1 Wavelength.
The velocity of ultrasound depends on the physical properties (density) of the tissue. I n soft
tissues such as heart muscle, ultrasound travels at 1540 m/s, but it is faster in bone and much
slower in air. A s ultrasound waves pass through the body, they encounter tissue interfaces of
different composition that reflect, sca7 er or refract the waves, rather like the effects of glass onlight (Fig. 1.2). I f ultrasound waves are reflected back to the echo probe and detected, a picture of
the heart can be built up. This is achieved by working out how long it takes the sound waves to
travel to the heart and back: the longer this takes, the further away the structure must be (Fig. 1.3).
Therefore an echo machine is continuously processing the raw data received by the transducer to
depict what is happening in the heart.
FIGURE 1.2 Ultrasound/tissue interactions.
Ultrasound emitted by the transducer (red arrow) encounters a structure
(rectangle). It may be reflected directly back (specular reflection: blue arrow),
scattered (green arrow) or pass through the tissue and either become
attenuated (purple arrow) or change course (refraction: dark blue arrow).FIGURE 1.3 Determination of relative distance.
(a) The time elapsing between the emission and receipt of ultrasound signals
allows the distance (D) between structures to be calculated. If an ultrasound
signal (red arrow) is emitted from the transducer the time taken for this to be
reflected back to the transducer by structure S will be twice the time taken2
for reflection back from structure S . (b) The visual representation of S and1 1
S on the echo screen: the transducer is considered to be at the apex of the2
triangular sector.
Conveniently, pericardium, endo-/epicardium and valves reflect ultrasound waves strongly
(specular reflection), whilst heart muscle causes sca7 ering, and blood causes li7 le reflection at all.
These differences in signal intensity allow blood and heart muscle to be easily differentiated on
Echocardiographic modes
Two-dimensional imaging
The most intuitive echo mode is two-dimensional (2D ) imaging, sometimes called B-mode,
which provides cross-sectional real-time moving images of the heart. There are different ways of
achieving this, but most modern echo machines use an array of crystals that are cyclically
activated and inactivated in phase. Each cycle effectively produces an arc of ultrasound lines that
can be compiled into a 2D image (Fig. 1.4). Repetition of this process hundreds of times per
second allows the motion of the heart to be appreciated. The quality of the image is determined
by the number of scan lines (usually over 100 per sector), and the frequency at which they are
repeated (frame rate: usually about 100 per second).FIGURE 1.4 Principle of two-dimensional imaging.
(a) Multiple ultrasound beams are emitted, forming an arc of ultrasound that
passes through the structures of the chest, including the heart. (b) Ultrasound
is scattered and reflected at tissue/blood interfaces back towards the
transducer. (c) The relative positions and timings of each reflected wave allow
a two-dimensional picture of the heart to be displayed. Clearly, increasing the
number of scan lines will improve the image quality. (d) Actual
twodimensional image.
Three-dimensional imaging
Real-time three-dimensional imaging is now available and is increasingly used in routine clinical
practice. This is discussed in detail in Chapter 21.
M-mode imaging
At one time this was the only available echo mode. I t uses a small group of crystals to produce a
single narrow beam of ultrasound, which can be analysed to locate the distance of structures from
the transducer. 2D images are used to guide placement of the M-mode cursor across the
structures of interest. The beam is repeated 1000s of times per second, and each analysis of
distance is plo7 ed against time (Fig. 1.5). The advantage of this mode is the very high frame rate,
so that the spatial resolution of moving structures is very good, and highly accurate measures of
cardiac dimensions can be achieved. The disadvantages are that the images can be difficult to
interpret, and reliable measurements require very good technique.