RESOLUTION AXIAL Front-to-back Parallel LARRD Longitudinal Axial Range Radial Depth Pulse length Shortest pulse Highest

frequency/shortest wavelength Fewest cycles in pulse (less ringing) No, same at all depths Shortest pulse Shortest pulse LATERAL Side-by-side Perpendicular LATA Lateral Angular Transverse Azimuthal Beam Width Narrowest Beam

Orientation Mnemonic

Determined by Best with

Does it change? In near field best with In far field best with

Yes, changes with depth Best at focus Smallest diameter crystal Largest diameter & Highest frequency (least divergence)

Axial resolution is superior to Lateral Resolution HIGH TEMPORAL RESOLUTION High Frame Rate Shallow Imaging depth Fewer pulses per image Single focusing Narrow sector Low line density Better movie, but low quality image Small packet size

PULSED SOUND Pulse Duration - Time the pulse is on - Sound source - Cannot change Pulse Repetition Period - Time from start to next start - listening time - Sound source - Changeable - Determined by depth of view Pulsed Repetition Frequency - Number of pulses per sec - Sound source - Changeable - NOT related to frequency - shallow image high PRF - inversely related to PRP Duty Factor - no units/% DF = PD/PRP - Sound source - Changeable Spatial Pulse Length - distance a pulse occupies - BOTH: source and medium - Cannot change - determines Axial resolution

Shallow imaging ~ High PRF ~ High Duty Factor ~ Short Pulse Repetition Period

PROPAGATION SPEED General Rule: Lung (air) << fat < soft tissue << bone Tissue type Air Lung Fat Soft tissue (blood) Tendon Bone Speed (m/s) 330 300-1200 1450 1540 m/s = 1.54 km/s = 1/54 mm/us 1850 2000-4000

RULE OF THUMBS: Stiffness and Speed same direction Density and Speed opposite direction Compressibility & Elasticity opposite of Stiffness works too Bulk modulus ~ Stiffness ATTENUATION NOT related to speed Increases when higher frequency Increases when longer path length Air >> Bone & Lung > Soft tissue > Blood > > Water Units: dB IMPEDANCE Property of the medium Calculated Units: Rayls Z = density (kg/m3) x speed (m/s) PZT > matching layer > gel > skin Note: matching layer is wavelength thick RANGE EQUATION Distance to boundary = time (us) x 0.77 mm/us The 13 us rule: In soft tissue, every 13 us of go-return time means reflector is 1 cm deeper in the body. TRANSDUCER ARCHITECTURE Active Element - PZT - ceramic - wavelength thick Case - protects internal components Wire - Conduit for voltage from US system to excite crystal to produce sound Matching Layer - increases efficiency of sound transmission Damping/Backing Element - Reduce ringing - *Short pulses create better images (shorter PD; shorter SPL) - increases bandwidth

Imaging Transducer Characteristics Damping is effective Short pulse length/duration Low sensitivity Wide bandwidth/broadband increases range of frequencies Low Q factor Decreased output power Q factor = resonant frequency (MHz) / bandwidth (MHz) SOUND BEAM Characteristic Frequency (CW) Frequency (pulsed) Focal Length Divergence Determined by Electronic Frequency Thickness of PZT & speed of sound in PZT DIAMETER of PZT & frequency of sound DIAMETER of PZT & frequency of sound

LARGE diameter HIGH frequency Narrower beam in far field/LESS divergence improved lateral resolution Near field length = (radius of transducer)^2 / wavelength Near field length directly related to frequency Large diameter crystals deep focus High frequency ( short wavelength) deep focus **recall: attenuation diminishes image quality despite deep focus A strongly focused transducer has a shallower depth than that of an identical but weakly focused transducer DISPLAY MODES X-axis Depth Depth Time Y-axis amplitude depth Z-axis amplitude

A-mode B-mode M-mode

PULSED ECHO COMPONENTS Six components Master synchronizer: organizes Transducer: converts energy Pulser: beam former Receiver: electronic processing/booster (Amplification, Compensation, Compression, Demodulation, Rejection) Display: presentation Storage: hard drive

Master Synchronizer Pulser Beam former Transducer Patient Transducer Receiver (preprocessing) Scan Converter (A to D converter/pre-processing --- Storage (post processing) --- D to A converter) Display Receiver Functions ADJUSTABLE SIGNAL PROCESSED Yes All signals treated equally Yes Signals treated differently based on depth Yes Decreases dynamic range; changes gray scale map NO Changes form of signals (negative to positive) Yes All weak signals manipulated; strong signals not affected IMAGE PROCESSING PREprocessing: BEFORE storage; cannot be undone TGC Log compression Write magnification/Zoom/Regional Expansion Fill-in interpolation Persistence (frame averaging) Spatial compounding Eliminating Aliasing Adjust the scale if same view Select new view with shallower sample volume (ie, decrease sector depth) Change transducer to lower frequency Use CW Doppler Shift baselineappearance only Increase PRF because Nyquist limit = PRF / 2 Six Assumptions of imaging systems Sound travels in a straight line Sound travels directly to a reflector and back Sound travels at 1540 m/s Reflections arise from structures positioned along beams main axis Intensity of reflections is related to scattering of tissue Imaging plane is thin POSTprocessing: AFTER storage; perfomed on frozen images Read magnification 3-D rendering

FUNCTION Amplification Compensation Compression Demodulation Rejection

1. 2. 3. 4. 5. 6.

Intensity = Power = Amplitude ^2

TRANSDUCERS Linear phased Array Elements in a line Microsecond delays between pulses Electronic beam steering determined by slope Electronic beam focusing determined by curvature Annular Array Concentric ring-shaped elements Inner for shallower; outer for deeper Multiple foci superior lateral resolution Reduced temporal resolution because of slower frame rate

ARTIFACTS Near field clutter Arises from high-amplitude oscillations of PZ elements Prevents operator from clearly identifying echogenic structures in near field Chiari Network Filamentous structures with rapid chaotic motion in RA Generally associated with orifice of IVC, origin is variable TEE INDICATIONS Indications for Operative TEE Category I (Supported by the Strongest Evidence or Expert Category II (Supported by Weaker Evidence and Expert Opinion) Consensus) Heart valve repair Heart valve replacement Removal of cardiac tumors Most congenital heart surgery requiring Increased risk of myocardial ischemia or hemodynamic cardiopulmonary bypass disturbances Endocarditis, particularly with extensive disease or Intracardiac thrombectomy or pulmonary embolectomy inadequate preoperative evaluation of disease extent Suspected cardiac trauma or for detection of foreign Ascending aortic dissection repair when aortic valve bodies involvement unknown Cardiac aneurysm repair Evaluation of life-threatening hemodynamic Thoracic aortic dissection repair without suspected aortic disturbances when ventricular function is unknown valve involvement Pericardial window procedures Evaluation of anastomotic sites during heart and/or lung Hypertrophic obstructive cardiomyopathy repair transplantation Monitoring placement and function of assist devices ASD Ostium secundum --- MVP (most common) Ostium primum --- Cleft in Mitral Valve Sinus venosus --- anomalous return of RUPV and RLPV Coronary sinus --- PLSVC VSD Supracristal = subarterial = outlet = subpulmonic = doubly committed = infundibular Perimembranous = Infracristal (most common) Muscular AV canal = inlet Coarctation of Ao Described relative to ligamentum arteriosum Preductal, juxtaductal or postductal Associated with bicuspid AV, PDA, VSDs, valvular AS, subaortic stenosis, Turner syndrome Elevated SBP in UE when compared with LE Radial to femoral pulse delay If preductal, cyanosis with exercise

Pericardial CONSTRICTION Hemodynamic characteristics o Impairment of diastolic ventricular filling o DISSOCIATION between intrathoracic and intracardiac pressures o EXAGGERATED ventricular interdependence in diastolic filling NOTE: normally > intrathoracic pressures declines during spontaneous inspiration With constriction, this decline doesnt happen as much so what happens is that the driving pressure for the left-sided filling pressure gradient between the pulmonary vein and left atrium is decreased during inspiration leading to decreased mitral inflow with decreased early mitral inflow velocity! Cardiac volume is fixed and the ventricles rely on each other for diastolic filling---- SOOO the decreased LV diastolic filling during inspiration causes the shift of ventricular septum to the LEFT ------> shift to left, more on right; therefore RV has increased early tricuspid inflow velocity opposite findings in expiration ECHO findings: Thickened pericardium Abnormal ventricular septal bounce Reciprocal respiratory variation Dilated IVC without respiratory variation M-mode shows flattening of LV posterior wall during diastole

Crawford for thoracoabdominal aneurysm Type I LSC artery above renal Type II LSC artery below renal Type III distal to LSC/above diaphragm below renal Type IV below diaphragm below renal

Debakey for Aortic dissections Type I asc Ao aortic bifurcation Type II asc Ao brachiocephalic trunk Type III LSC above diaphragm (IIIa) or aortic bifurcation (IIIb)