Aaron Lassmann

ISM- Period 7
Singh, Siddharth, and Abha Goyal. The Origin of Echocardiography: A Tribute to Inge Edler.
Texas Heart Institute Journal 34.4 (2007): 431438. Print.

Lazzaro Spallanzani (1729 1799) demonstrated that bats communicate through echoed
sound.
1915- SONAR developed using the premise; RADAR also developed based on the
concept.
Inspired by RADAR, in 1946, French physiotherapist Andr Denier proposed using
sound to obtain images of internal organs
Early American attempts failed, despite being leaders in the field of advanced electronics.
1941- Austrian neurologist, Karl Theo Dussik applied ultrasound to medical diagnosis,
using it to outline the ventricles of the brain.
After a decade of work, his efforts never came to fruition due to reflection of the sound
waves by the bony structure of the cranium
German physicist, Wolfe Dieter Keidel imagined the use of ultrasound for recording the
heart in the late 1940s.
Inge Edler was born on March 17, 1911 in Burlv, Malmhus county, at the southern tip
of Sweden.
He was interested in physics throughout high school, but initially chose to become a
dentist due to influence from his older sister who was a dentist.
Edler attempted to enter dental school too late in the year, so he enrolled in medical
instead.
Captivated by medicine, Edler went on to receive his medical degree from Lund
University in 1943.
Edler was passionate in the field of cardiology and became the director of the
Cardiovascular Laboratory at the University Hospital of Lund.
In the late 1940s, surgery of the heart was started at the University Hospital of Lund.
Surgeons inserted a finger in the valve of patients during surgery to alleviate mitral
stenosis; however, some patients still worsened afterwards due to mitral regurgitation.
The only way to diagnose this valve incompetence was through invasive and elaborate
cardiac catheterization.
Inspired by RADAR, Edler worked with physicist Hellmurth Hertz, eventually
developing M-mode echocardiography
On October 29, 1953, Edler and Hertz recorded the first moving pictures of the heart.
Edler and Hertzs work stimulated work with ultrasound in neurology, obstetrics, and
gynecology.

This article covers Inge Edler and his creation of echocardiography step-by-step in great detail,
providing a completely comprehensive source on the history of echocardiography with minute
details at every step of history.

Aaron Lassmann
ISM- Period 7
Ashley, Euan A., and Josef Niebauer. "Understanding the Echocardiogram." Cardiology
Explained. London: Remedica, 2004. N. pag. Print.

Ultrasound waves in the range of 47 MHz are used for adult cardiac imaging.
The waves are created in the probe by striking piezo-electric crystals with an electric
pulse, stimulating the crystals to release sound waves.
Most waves are absorbed by the body, but some of the waves at the interfaces between
different tissues are reflected or echoed back.
The echoes are detected and processed by the probe or transducer. They are then formed
into the characteristic images.
The three basic modes to cardiac imaging are two-dimensional (2D) imaging, M-mode
imaging, and Doppler imaging.
Two-dimensional imaging is the most commonly used form and the mainstay of
echocardiography.
It allows a cross section of the heart to be viewed moving in real-time. This helps in
detecting abnormal anatomy or abnormal movement of structures.
The most common views looked at are the parasternal long axis, the parasternal short
axis, and the apical view. Other common views are the subcostal and suprasternal views.
M-mode echocardiography provides a one-dimensional view and is used primarily for
fine measurements.
Doppler imaging allows for estimates of blood-flow velocity to be made.
These estimates are made by comparing the frequency of the transmitted sound with that
of the reflected sound.
There are three ways to use Doppler in cardiac ultrasound: continuous-wave (CW)
Doppler, pulsed-wave (PW) Doppler, and color-flow mapping (CFM)
CW Doppler measures velocity along the entire length of the ultrasound beam and is used
to estimate the severity of valve regurgitation by measuring the shape or density of the
output.
PW Doppler measures the blood-flow velocity across a small area at a specific tissue
depth.
CFM measures velocity and direction of blood flow, superimposing this data in color on a
two-dimensional image.
Transesophageal echocardiography involves the insertion of a probe down the esophagus
to provide clear images of the posterior areas of the heart.
Echocardiography is the cheapest and least invasive method of cardiac screening.

This article provides a concise and informative description of the various forms of
echocardiography beyond what is even described above, making it an extremely useful source
for accurate and easily comprehendible information of echocardiography in all its extents.

Aaron Lassmann
ISM- Period 7
Hung, Judy, et al. "3D Echocardiography: A Review of the Current Status and Future
Directions." Journal of the American Society of Echocardiography 20.3 (2007): 213-33.
American Society of Echocardiography. American Society of Echocardiography, Mar.
2007. Web. 2 Nov. 2015.

First attempts at recording and displaying 3D ultrasound were in the 1960s

3D showed promise as an accurate and ideal method to displaying anatomy, but was
limited by the large amount of computational power it required.
Over a decade later, the first 3D ultrasounds of the heart began to be obtained through the
careful tracking of the transducer and the combining of the 2D images. This method was
limited by the need for offline data processing.
Von Ramm and colleagues created a machine that collected the first real-time 3D
images of the heart in the early 1990s.
Current real-time 3D imaging transducers contain over 3000 imaging elements.
These current matrix-array transducers offer improved resolution and are rapidly
becoming the primary technique for 3D data acquisition in clinical and research
practice.
Recent improvement in transducer technology is resulting in smaller transducer footprint,
improved side-lobe suppression, greater sensitivity and penetration, and harmonic
capabilities that may be used for both gray-scale and contrast imaging.
Storage systems can easily be overwhelmed by 3D imaging with a one second loop
running about 50 MB.
Compression of can reduce the size to about a third. Modern and emerging algorithms
potentially allow for an even greater reduction in file size without losing image quality.
Accurate calculation of left ventricular volume is possible through 3D imaging.
3D imaging of the right ventricle is limited as it is with 2D due to its location and shape.
There is improvement in the imaging of the right ventricle, but is requires significant
postprocessing, limiting its widespread application. Work is being made towards realtime imaging of the right ventricle.
In limited studies, the volume of the left atrium has been accurately calculated with 3D.
3D imaging allows for a new perspective in evaluating valve abnormalities.
Improves and automated extraction and quantification of 3D is in development and will
improve the resolution, capabilities, and clinical usage of 3D echocardiography.

This entry from a journal on echocardiography provides useful information on 3D imaging, an

advancing area of echocardiography that I am highlighting in my presentation, which makes this

source extremely important in providing some history and statistics surrounding 3D imaging that
I do not learn through my hours at the clinic.
Aaron Lassmann
ISM- Period 7
Peterson, Gail E., M. Elizabeth Brickner, and Sharon C. Reimold. "Transesophageal
Echocardiography: Clinical Indications and Applications." Circulation 107.19 (2003):
2398-402. Web. 4 Nov. 2015.

Transesophageal echocardiography (TEE) is invasive form of echocardiography were the

transducer is placed down the patients esophagus, so that clear images can be obtained
without interference from the ribs and lungs.
The short distance of the probe to heart allows for the use of higher frequencies and the
production of higher quality images.
TEE is commonly and primarily utilized as a diagnostic tool for issues pertaining to the
heart.
TEE allows for the viewing of any thrombi in the heart caused by an arrhythmia, which
could eventually become dislodged and result in a blockage somewhere in the blood
vessels of the body.
Transesophageal echocardiography can also be used in the diagnosis of atrial fibrillation,
commonly referred to as A-fib.
A-fib is an arrhythmia, which can cause blood to coagulate and thrombi to form due to
the inefficient pumping of the blood.
With the uses relating to thrombi, TEE can be done multiple times to assess how well
anticoagulation treatments are working in dissolving the thrombi.
TEE, in conjunction with transthoracic imaging, provides for the excellent evaluation of
prosthetic heart valves.
With transthoracic echocardiography (TTE), prosthetic mitral and tricuspid regurgitation
may not be visualized because of reverberation artifacts and inadequate ultrasound
penetration beyond a mechanical valve. The posterior positioning of TEE allows for a
much better imaging of regurgitation in these valves.
TEE is a rapid and reliable tool for the diagnosis of aortic dissection, allowing
differentiation of dissection from intramural hematoma and penetrating aortic ulcers.
TEE can be used in conjunction with surgery to provide an evaluation of the heart prior to
surgery, confirm suspected diagnoses and the need for surgery, and follow changes in the
patient post-surgery.
Transesophageal echocardiography, like all areas of echocardiography, is a still advancing
field with contrast methods potentially providing clearer and even more accurate images
and 3D imaging being applied to TEE to provide accurate evaluation of volume and
valves of the heart.

Transesophageal echocardiography is unlike other forms in that it is invasive, placing the

transducer down the esophagus, so the information in this article provides useful information for
contrasting this form of echocardiography with the other noninvasive forms.
Aaron Lassmann
ISM- Period 7
Adams, David, and Emily Forsberg. "Conducting a Cardiac Ultrasound Examination."
Echocardiography. By Petros Nihoyannopoulos and Joseph A. Kisslo. Dordrecht:
Springer, 2009. 31-46. Print.

Ultrasonic access to the heart is made difficult by the bony structure of the protective
ribcage and the air in the surrounding lungs.
Ultrasound is able to penetrate through a few specific windows in the rib area.
The left parasternal window provides the best images for most echocardiograms, which
need to be perpendicular to the heart structures.
The left parasternal long-axis view of the left ventricle allows for the evaluation of the
left ventricular chamber size, performance, septal wall thickness and motion, aortic valve
and aortic root, overriding aorta, mitral valve, and left atrium.
The left parasternal long-axis view of the right ventricular inflow allows for the
evaluation of right atrial and right ventricular dimensions, mass lesions, and tricuspid
valve abnormalities.
The left parasternal short-axis from base to apex allows for the evaluation of the aortic
valve, mitral valve, left ventricular wall motion, wall thickness, and chamber size. It
produces cross-sections of the heart from base to apex.
The left parasternal short-axis of the great arteries allows for the evaluation of the spatial
orientation of the great arteries and abnormalities in the aortic, tricuspid, and pulmonic
valves.
There are many more short-axis views that can be utilized for imaging.
The apical window is captured from a location in proximity to the apex of the heart,
giving the view its name.
The three forms of apical viewing, four-chamber; long-axis; and two-chamber, show full
side on views of the heart, with areas ranging from all four chambers, the left side and the
aortic valve, and the two chambers of the left side, respectively.
The subcostal window comes from below the costals as the name suggests and consists of
three different views: four-chamber, short-axis left ventricular, and long-axis inferior
vena cava.
The suprasternal window is a viewing area found on the suprasternal notch and the
angulus Ludovici; it provides a long-view of the aorta and short-axis view of the right
pulmonary artery.
For transesophageal imaging, there is an infinite number of view areas and windows due
to the lack of rib or lung impedance of the image.

This chapter from a textbook on echocardiography covers the various viewing angles and
techniques of echocardiography, which is very useful because much of the content is jargon that
gets thrown around at my mentorship without thorough explanation to me on what it means.