State of the Art Techniques in Critical Care Echocardiography : 3D, Tissue, Contrast

This book covers all aspects of modern techniques used in the rapidly developing field of adult critical care echocardiography, 3D transthoracic and transesophageal echocardiography, myocardial tissue velocity and deformation assessment, and contrast echocardiography. Featuring multiple color illustrations and echocardiographic images, it provides essential information on the technical aspects and current specifics of the equipment, anatomical imaging guidance, and physiological and pathological approaches with a focus on critically ill population. This book helps practitioners to not only understand the techniques and the applicability of these new technologies in various disease states, but also to apply them in a clinical setting. 3D echo, tissue deformation and contrast are opening tremendous new horizons for intensive care practitioners, offering them previously unimaginable insights into cardiac mechanics and anatomy and using non-invasive approaches for central hemodynamic diagnostic and monitoring management of intensive care patients. It also opens the way for completely new areas in clinical research. This book is useful for intensive care physicians, cardiologists, anesthesiologists, emergency physicians and sonographers involved in the provision of advanced echocardiographic services in intensive care units and in critical care environments. It is also suitable for students undertaking a Diploma of Diagnostic Ultrasound (Critical Care) with the Australasian Society of Ultrasound Medicine, adding to the existing literature used to prepare for the second and third parts examinations. Foreword 5 Preface 7 Acknowledgements 9 Contents 10 Abbreviations 15 About the Editor 16 1: 3D Echocardiography in Critical Care 17 1.1 Introduction 17 1.2 Historic Perspective of 3D Echocardiography 18 1.3 The Technology 19 1.4 The Challenges 20 1.4.1 The Heat 20 1.4.2 The Data 21 1.4.3 Stitched Pyramids 21 1.4.4 The Footprint 22 1.4.5 The 3D Paradox of 2D Displays, the Colour, the Transparency and Other Tricks of Animation 24 1.4.6 The Future has Arrived 26 1.5 3D Modalities 27 1.5.1 Real-Time 27 1.5.2 Thick Slice 29 1.5.3 Zoom 34 1.5.4 Full Volume 35 1.5.5 Cropped Volume 36 1.5.6 Bi-Plane 43 1.5.7 Colour Doppler 45 1.5.8 The 3D Nature of Tissue 50 1.5.9 3D Vorticity 50 1.5.10 3D Contrast 50 1.5.10.1 Opacification 51 1.5.10.2 Perfusion 53 1.6 Settings 53 1.7 Image Acquisition 55 1.8 Image Presentation 56 1.8.1 Volume Rendering (Reality Simulation) 56 1.8.2 Surface Rendering (Animation Modelling) 57 1.8.3 Valvular Endocardium (Surface, Volume and a Combination of all Renders) 62 1.8.4 Tomographic Slices (Slices Rendering) 63 1.9 3D Transthoracic Echocardiography 65 1.9.1 Parasternal Window 66 1.9.2 Apical Window 69 1.9.3 Subcostal Window 76 1.9.4 Suprasternal Window 82 1.10 3D Transoesophageal Echocardiography 83 1.11 LV Assessment 92 1.11.1 LV with 3D TTE (Global and Regional) 92 1.11.2 LV with 3D TOE 98 1.11.3 LV 3D Contrast Opacification 99 1.12 RV Assessment 100 1.13 Atrial Assessment 106 1.13.1 Left Atrium 106 1.13.2 Right Atrium 118 1.14 Cardiac Valves 128 1.14.1 Mitral Valve 128 1.14.1.1 3D TTE and Mitral Valve 130 1.14.1.2 3D TOE and Mitral Valve 130 1.14.1.3 3D Colour Doppler 135 1.14.1.4 3D PISA 137 1.14.1.5 3D Colour Doppler Flow Quantification 138 1.14.1.6 Prosthetic MV 148 1.14.2 Aortic Valve 155 1.14.2.1 3D TTE and AV 155 1.14.2.2 3D TOE and AV 156 1.14.2.3 3D Colour Doppler and AV 158 1.14.2.4 Prosthetic AV 164 1.14.3 Tricuspid and Pulmonary Valves 167 1.15 Thoracic Aorta 172 1.16 Mechanical Circulatory Support 177 1.16.1 ECMO 177 1.16.2 LVAD 180 1.16.3 RVAD 187 1.17 Other Directions 189 1.17.1 3D Tissue 189 1.17.2 3D Fusion Imaging 190 1.18 Conclusions and the Future 190 Suggested Reading 192 2: Myocardial Tissue Characterization with Echocardiography in Critical Care 196 2.1 Introduction 196 2.2 Tissue Doppler Imaging (TDI) 197 2.2.1 Spectral TDI 198 2.2.2 Colour TDI 207 2.2.3 Tissue Velocity-Based Deformation Imaging 219 2.3 Speckle Tracking 221 2.3.1 Principles of Speckle Tracking Deformation Imaging 223 2.3.2 Strain 225 2.3.3 Longitudinal Strain 227 2.3.4 Strain Rate 228 2.3.5 Terminology and Parameters 231 2.4 Clinical Myocardial Deformation Imaging 233 2.4.1 How to Perform Speckle Tracking Echocardiography 234 2.4.2 Image Optimization for LV Strain 234 2.4.3 Image Optimization for RV Strain 235 2.4.4 Image Optimization for Atrial Strain 238 2.4.5 The Process of Speckle Tracking Analysis 240 2.4.6 Rotational Deformation 248 2.5 Variability of Strain 252 2.5.1 Inter-Vendor Differences 252 2.5.2 Reproducibility 252 2.5.3 Potential Areas of Clinical Use in ICU 252 2.6 Left Ventricular Systolic Function 254 2.6.1 Longitudinal Strain and Septic Cardiomyopathy 254 2.6.2 Left Ventricular Strain Rate 262 2.6.3 Regional Wall Motion Abnormalities 263 2.7 Left Ventricular Diastolic Function 272 2.8 Dyssynchrony 275 2.9 Twist and Torsion 278 2.9.1 Mechanisms 278 2.9.2 Systolic 279 2.9.3 Diastolic 282 2.9.4 Summary 283 2.9.5 Future Directions 283 2.10 RV Free Wall Strain 284 2.10.1 Underlying Principles 284 2.10.2 The Process of Analysis 285 2.10.3 Applications in Critical Care 285 2.10.4 The Future 293 2.11 Atrial Strain 295 2.11.1 Basics 295 2.11.2 Gating 295 2.11.3 Atrial Strain Applications in ICU 298 2.11.4 The Process of Analysis 300 2.11.5 The Future Potential of LA Strain in ICU 301 2.11.6 RA Strain 301 2.12 Two- and Three-Dimensional Speckle Tracking 305 2.13 Why the 3D LV Deformation Imaging? 309 2.14 Why the 3D RV Deformation Imaging? 310 2.15 STE and Mechanical Cardiac Support 310 2.16 Non-cardiac Uses of STE 311 2.17 Myocardial Echocardiographic Tissue Elastography 313 2.18 Conclusions 317 Suggested Reading 318 3: Contrast Echocardiography in Critical Care 324 3.1 Introduction 324 3.2 Echo Contrast Agents Over-View 325 3.2.1 Spontaneous Contrast 325 3.2.2 Injected Contrast 326 3.3 Right-Sided Contrast Agents 330 3.3.1 Agitated Saline 330 3.3.2 Agitated Colloids 330 3.3.3 Agitated Autologous Blood 331 3.3.4 Indications 332 3.3.4.1 Interatrial Shunt Detection with TTE 332 3.3.4.2 Interatrial Shunt Detection with TOE 337 3.3.4.3 Ventricular Shunt Detection 340 3.3.4.4 Differential Diagnosis of Hypoxaemia 340 3.3.4.5 Improvements in Doppler Signal 340 3.3.4.6 Procedural Assistance 347 3.3.4.7 Right-Sided Contrast and ECMO 347 3.3.5 Risks 349 3.4 Manufactured Contrast Agents 350 3.4.1 First Generation 350 3.4.2 Second Generation 351 3.4.3 Definity® 352 3.4.3.1 Physical Characteristics 352 3.4.3.2 Pharmacokinetics 353 3.5 The Physics of Contrast Imaging 354 3.5.1 The Mechanical Index 355 3.5.2 Tissue Backscattering Properties 355 3.5.3 Microbubble Backscattering Properties 355 3.5.4 Tissue and Bubble Response to Frequency 356 3.5.5 Microsphere Size 358 3.6 Manufactured Contrasts Administration 358 3.6.1 Bolus or Infusion 358 3.6.2 Author’s Approach to the Technique 359 3.7 Indications for Manufactured Contrast Administration 359 3.8 Clinical Applications of Contrast Echocardiography 360 3.8.1 Chamber Opacification 360 3.8.1.1 Chamber Quantification 361 3.8.1.2 Stress Echocardiography in ICU 361 3.8.1.3 After Cardiac Surgery 361 3.8.1.4 Regional Wall Motion Abnormalities 361 3.8.2 Morphology 368 3.8.2.1 Variant of Normal or Pathology 368 3.8.2.2 Apical Hypertrophic Cardiomyopathy 369 3.8.2.3 Interventricular Septum 372 3.8.3 Masses 377 3.8.3.1 Tumours 378 3.8.3.2 Left Atrial Appendage 384 3.8.3.3 Right Heart Masses 386 3.9 Perfusion 387 3.9.1 Underlying Principles 388 3.9.2 Quantification 390 3.10 Extravasation of Contrast 392 3.11 Doppler Enhancement by Manufactured Contrast Agents 395 3.12 Contrast Echocardiography Practice Points 398 3.13 Workflow Sequence in Contrast Imaging 399 3.13.1 Transthoracic Echocardiography 399 3.13.2 Transoesophageal Echocardiography 399 3.13.3 Left Ventricular Apical Imaging 401 3.14 Contrast Echocardiography in Mechanical Cardiac Support 403 3.15 Manufactured Contrast Safety and Contra-Indications 405 3.16 Contrast Artefacts 407 3.16.1 Attenuation 407 3.16.2 Swirling 408 3.16.3 Rib Artefact 409 3.16.4 Blooming 410 3.17 Future Directions 410 3.18 Conclusion 412 Suggested Reading 412 Front Matter ....Pages i-xix 3D Echocardiography in Critical Care (Konstantin Yastrebov)....Pages 1-179 Myocardial Tissue Characterization with Echocardiography in Critical Care (Sam Orde, Konstantin Yastrebov)....Pages 181-308 Contrast Echocardiography in Critical Care (David Platts, Konstantin Yastrebov)....Pages 309-401