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«AD-COR Program inovativ de formare in domeniul cardiologiei pediatricePOSDRU/179/3.2/S/152012”
Iunie 2015
MODUL TEORETIC
INTRODUCERE IN ECOCARDIOGRAFIE
Continut documentat/ validat/ prezentat de:
Expert formare medici: NICOLESCU Alin
Expert formare medici: VEDUTA Alina
Expert formare asistente: FILIP Cristina
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Ecoul
• daca strigam intr-un put, ecoul se intoarce dupacateva momente;
• ecoul apare pentru ca undele sonore se reflectape o suprafata (fie apa din fundul putului, fie peretiiputului), si se intorc sprenoi;
• un principiu similar se aplica si in ultrasonografiacardiaca
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Notiuni despre fizica ultrasunetelor(1)
• Sunetul = unda mecanica transmisa printr-un mediuelastic ce contine particule care vibreaza, permitandpropagarea sunetului
• Sunetele cu o frecventa>20.000Hz= ultrasunete
• Reprezentarea grafica a undei acustice:
-sinusoida, cu zone de compresie si rarefactie;-1 compresie+ 1 rarefactie= 1ciclu;-numarul de ciclii/sec= frecventa undei sonore;-distanta dintre 2 puncte similare= lungimea de
unda;-lungime de unda micafracventa mare;-unitatea de masura pentru frecventa=Hz=1
ciclu/secunda;-gama de frecvente folosite in medicina: 2MHz-
40MHz ( 2-5MHz in ecografia transtoracica).
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Notiuni despre fizica ultrasunetelor(2)
Viteza cu care ultrasunetele emise de transductor se propaga prin tesuturieste proportionala cu densitatea acestora. Viteza medie de propagare a ultrasunetelor in corpul uman=1540m/s.
λ= v/f λ=lungimea de unda a ultrasunetelorv=viteza de propagare a ultrasunetelor in tesutf=frecventa ultrasunetelor emise de transductor
La interfata dintre doua medii cu densitatidiferite, ultrasunetele se reflecta sise refracta, ceea ce sta la baza formariiimaginii ecocardiografice.
Reflectia depinde de impedanta acusticadintre 2 medii: cu cat acesta este maimare, cu atat se reflecta mai mult din fasciculul incident (gelul reduce diferentade impedanta dintre medii).
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Notiuni despre fizica ultrasunetelor(3)
• Reflectia speculara: lungimea de undaintalneste o structura mare si neteda => reflectia se produce pe aceeasi directie
• Fenomenul de scattering: lungimea de unda intalneste o suprafata rugoasa => reflectia nu se produce pe aceeasi directie; se imprastie.
• Fenomenul de scattering sta la bazaimagisticii Doppler. Permite vizualizareaparticulelor paralele cu fasciculul; permitevizualizarea in scale de gri.
• Efectul Doppler: 2 obiecte in miscarerelativa: frecventa undei emise este maiinalta daca obiectul se apropie, si invers
• Atenuare: puterea semnalului se reduce progresiv datorita absorbtiei energiei US prin conversie catreecaldura
➢ Aerul are o impedanta acustica inalta cu atenuare semnificativa in contrast cu lichidul
❖ Pneumotorax/pleurezie
Ultrasunetele trimise dinspre pereteletoracic
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Armonici
• Unda de US trecand prin tesut devinedistorsionata,generandu-se frecvente sonoreaditionale care sunt armonici ale frecventeioriginale
• Se folosesc transductoare care pot receptionatransmisia acestor frecvente
• Imaginea este mult imbunatatita
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Optimizarea imaginii 2-D
-factori tehnici-
• Transductorul:-frecventa inalta: creste retrodifuziunea sirezolutia, dar nu are o buna penetrare;
-frecventa joasa: permite o buna penetrare, dar reduce rezolutia imaginii;
• Adancimea:-cu cat este mai mare adancimea, cu atateste mai mic frame-rate-ul;
-cautam cea mai mica adancime care permiteafisarea regiunii de interes ;
• Focusul: indica zona imaginii in care raza ultrasunetului estecea mai ingusta; rezolutia este cea mai buna in aceastaregiune;
• Gain-ul: ajusteaza amplitudinea tuturor semnalelor afisate.
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Pe scurt
undelesonore
trimise printransductor
reflectate de diferite
structuri ale cordului
ecouri, care sunt
convertitein imagini
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Originea ecocardiografiei(1)
• 1842-Christian Johann Doppler-noteaza ca frecventa undei sonorevariaza daca sursa sunetului se misca;
• Lazzaro Spallanzani- arata ca ecourilereflectate ale sunetelor neauzibilepermit liliecilor sa navigheze;
• Langevin in 1915, dezvolta sistemulSONAR (Sound navigation and ranging) folosit pentru detectareasubmarinelor inamice in primul razboimondial;
• In 1941 in cel de-al 2 lea razboimondial, armata Statelor Unite foloseste undele radio pentrudetectarea avioanelor, o tehnologienumita RADAR (Radio detection and ranging);
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Originea ecocardiografiei(2)• In 1946- Andre Denier propune
folosirea ultrasunetelor pentruvizualizarea organelor interne ale corpului uman
• In 1953 Edler si Hertz, in laboratorul Universitatii din Lund pun sonda de ultrasunetedeasupra inimii lui Hertz, si, spre fascinatia lor, vad un ecoumiscandu-se inainte si inapoi de-a lungul axei-X a ecranuluiosciloscopuli la o adancime de 8-9cm de la peretele toracic
• In octombrie 1953 cu UltraschallImpulsgerat, Inge Edler siHelmuth Hertz au inregistratprima imagine in miscare a cordului, inaugurandecocardiografia (Ultrasound cardiography)
• Inge Edler (stanga) and Carl Hellmuth Hertz, echipacardiolog-fizician care a datlumii ecocardiografia, la un simpozion in Lund, Suedia, 1977.
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Aparatul
Are 5 componente de baza:
1. generatorul de impuls: foloseste voltaj de mare amplitutinepentru a energiza cristalele
2. transductorul: converteste enrgia electrica in energie mecanica
3. receptorul: detecteaza si amplifica semnalele slabe
4. monitorul: prezinta semnalele in variate moduri
5. memoria
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• se recomanda selectarea sondei cu cea mai mare frecventacare permite o penetrare adecvata a structurilor de examinat;
• la pacientii slabi/copii, la care penetranta nu reprezinta o problema sunt optime sondele de frecventa mai inalta, care permit o buna rezolutie;
• in cazul unui perete toracic mai gros (pacienti obezi), devinenecesara folosirea unei frecvente joase.
marker
Sonda nou-nascuti 12-4
Sonda copii mici 8-3 Sonda copiimari/adulti 5-1
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ultrasound examination of the
heart
pediatric cardiologist
diagnosis research
neonatologist
PDA/
pulmonary hypertension
functional
emergency/
ICU
point of carehaemodynamic
anaestheticuse
haemodynamic/
residual defects
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Planurile ortogonale
Planurile ortogonale ale Planurile ortogonale ale
corpului cordului
Long-axis planes
Short-axis plane
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Miscari ale transductorului:
• Rotatie: in sensorar/antiorar;
• Angulare: in directiecraniala, caudala, sprestanga sau spare dreapta.
• Translatie: un spatiu maisus/mai jos/lateral/medial
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Sectiuni standard in ecocardiografie
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1. parasternal ax lung
2. parasternal ax scurt
3. apical 4 camere
4. subcostal
5. suprasternal
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Sectiunea parasternal ax lung
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Sectiunea parasternal ax lung(2)
Guidelines and Standards for Performance of a Pediatric Echocardiogram: A Report from the Task Force of the Pediatric Council of the American Society of Echocardiography
Wyman W. Lai, MD, MPH, FASE, Tal Geva, MD, FASE, Girish S. Shirali, MD,Peter C. Frommelt, MD, Richard A. Humes, MD, FASE,Michael,M. Brook, MD,Ricardo H. Pignatelli, MD, and Jack Rychik, MD, Writing Committee, New York, New York;Boston, Massachusetts; Charleston, South Carolina; Milwaukee, Wisconsin; Detroit, Michigan; San Francisco, California;Houston, Texas; and Philadelphia, Pennsylvania
Sectiuni modificate ax lung:-pentru tractul de intrare VD: prin angulare spre superior si lateral
fata de pozitia necesara obtinerii sectiunii parasternale ax lung;-pentru tractul de iesire VD: angulare in sens invers.
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Sonda se plasezain spatiul III, IV sau V intercostal stang; markerulsondei orientatcatre claviculadreapta a pacientului,ora11.
Sectiunea parasternal ax lung(1)
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Sectiunea parasternal ax scurt
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Sectiunea parasternal ax scurt(2)
Guidelines and Standards for Performance of a Pediatric Echocardiogram: A Report from the Task Force of the Pediatric Council of the American Society of Echocardiography
Wyman W. Lai, MD, MPH, FASE, Tal Geva, MD, FASE, Girish S. Shirali, MD,Peter C. Frommelt, MD, Richard A. Humes, MD, FASE,Michael,M. Brook, MD,Ricardo H. Pignatelli, MD, and Jack Rychik, MD, Writing Committee, New York, New York;Boston, Massachusetts; Charleston, South Carolina; Milwaukee, Wisconsin; Detroit, Michigan; San Francisco, California;Houston, Texas; and Philadelphia, Pennsylvania
• Prin angularea catre inferior si lateral, fata de pozitia anterioara a sondei, se poate vizualiza axul scurt al VS la diferite niveluri: valvei mitrale; muschilorpapilari; apexului
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fata de pozitia sondei din parasternal ax lung, prin rotire cu aproximativ 90⁰ in sensul acelorde ceasornic: baza marilor vase.
Sectiunea parasternal ax scurt(1)
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Sectiunea apical
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Sectiunea apical patru camere
Guidelines and Standards for Performance of a Pediatric Echocardiogram: A Report from the Task Force of the Pediatric Council of the American Society of Echocardiography
Wyman W. Lai, MD, MPH, FASE, Tal Geva, MD, FASE, Girish S. Shirali, MD,Peter C. Frommelt, MD, Richard A. Humes, MD, FASE,Michael,M. Brook, MD,Ricardo H. Pignatelli, MD, and Jack Rychik, MD, Writing Committee, New York, New York;Boston, Massachusetts; Charleston, South Carolina; Milwaukee, Wisconsin; Detroit, Michigan; San Francisco, California;Houston, Texas; and Philadelphia, Pennsylvania
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Sectiunea apical
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Sectiunea apical
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Sectiunea apical patru camere
• Sonda se plaseaza cat maiposterior, in vecinatateasocului apexian, in general in spatiul V intercostal stg, pelinia axilara anterioara; markerul sondei se orienteazacatre ora 3.
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Sectiunea apical 5 camere
• Prin angulareanterioara a sondeipana la cuprinderea in imaginea 4C a tractului de ejectie VS si a valvei aortice: sectiune apical 5 camere
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Sectiunea apical doua camere
• Fata de pozitia necesara pentru obtinerea imaginii apical 4C, se rotesete sonda in sens invers acelor de ceasornic cu aproximativ 45-60⁰
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Sectiunea subcostal
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Sectiunea subcostal ax lung
Guidelines and Standards for Performance of a Pediatric Echocardiogram: A Report from the Task Force of the Pediatric Council of the American Society of Echocardiography
Wyman W. Lai, MD, MPH, FASE, Tal Geva, MD, FASE, Girish S. Shirali, MD,Peter C. Frommelt, MD, Richard A. Humes, MD, FASE,Michael,M. Brook, MD,Ricardo H. Pignatelli, MD, and Jack Rychik, MD, Writing Committee, New York, New York;Boston, Massachusetts; Charleston, South Carolina; Milwaukee, Wisconsin; Detroit, Michigan; San Francisco, California;Houston, Texas; and Philadelphia, Pennsylvania
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Sectiunea subcostal ax scurt
• Subcostal 4 camere:pacientul in decubit dorsal, genunchii in flexie pentru relaxareaabdomenului, se plaseaza sonda subxifoidian, pe linia mediana a corpului(eventual usorcatre dreapta pacientului). Sonda este angulata catre anterior si dreapta, astfel inactfasciculul de ultrasunete sa fie orientat catre umarul stang. Markerul sondei este orientatcatre ora 3.
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Sectiunea subcostal ax scurt
Guidelines and Standards for Performance of a Pediatric Echocardiogram: A Report from the Task Force of the Pediatric Council of the American Society of Echocardiography
Wyman W. Lai, MD, MPH, FASE, Tal Geva, MD, FASE, Girish S. Shirali, MD,Peter C. Frommelt, MD, Richard A. Humes, MD, FASE,Michael,M. Brook, MD,Ricardo H. Pignatelli, MD, and Jack Rychik, MD, Writing Committee, New York, New York;Boston, Massachusetts; Charleston, South Carolina; Milwaukee, Wisconsin; Detroit, Michigan; San Francisco,California;Houston, Texas; and Philadelphia, Pennsylvania
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Sectiunea subcostal ax lung
• Subcostal ax scurt: fata de pozitiaanterioara, se roteste sonda cu aproximativ 90⁰ in sens inversacelor de ceasornic; markerulsondei este orientat catre ora 12.
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Sectiunea suprasternal
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Sectiunea suprasternal
Guidelines and Standards for Performance of a Pediatric Echocardiogram: A Report from the Task Force of the Pediatric Council of the American Society of Echocardiography
Wyman W. Lai, MD, MPH, FASE, Tal Geva, MD, FASE, Girish S. Shirali, MD,Peter C. Frommelt, MD, Richard A. Humes, MD, FASE,Michael,M. Brook, MD,Ricardo H. Pignatelli, MD, and Jack Rychik, MD, Writing Committee, New York, New York;Boston, Massachusetts; Charleston, South Carolina; Milwaukee, Wisconsin; Detroit, Michigan; San Francisco, California;Houston, Texas; and Philadelphia, Pennsylvania
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Sectiunea suprasternal
• Pacientul in decubit dorsal sigatul in hiperextensie: se plaseaza sonda in incizurasuprasternala, cu angularea eicatre inferior si anterior astfelincat sa fie aproape paralelacu traheea. Markerul sondeieste orientat catre ora 1.
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Sectiunea suprasternal
• Fata de pozitia precedenta, daca se roteste sonda cu aproximativ 90⁰ in sensulacelor de ceasornic, se obtine sectiunea suprasternala perpendiculara pe aorta. Markerul sondei este orientat catre ora 4.
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• Inainte de inceperea ecografiei:
• CONSULTATI PACIENTUL
• CONSULTATI PACIENTUL
• CONSULTATI PACIENTUL
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• Paralel cu ecografia: inregistrare EKG;
• O structura cardiaca se examineaza intotdeauna din celputin din 2 planuri ortogonale;
• Necesitatea unui algoritm de examinare de la care sa nu ne abatem: examinarea sistematica a structurilor (preferabil in ordinea curgerii sangelui) in fiecare sectiune, in secventa: 2D (+ M-mode)->Doppler color ( +/- M-mode)->Doppler spectral
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Situatii particulare de obtinere a
sectiunilor
• Dextrocardie: se folosescferestre/sectiuniecocardiografice “in oglinda” cu celeprezentate;
• In caz de revarsatepleurale mari: se incearca obtinereade imagini prinplasarea sondei la nivelul pereteluitoracic posterior, cu pacientul in pozitiesezanda.
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Ductal cut view
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TREI SEGMENTE CARDIACE
ATRIU VENTRICULMARILE
VASE
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Tipuri de examinare ecocardiografica
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