Explaining Echocardiography and the Transthoracic Echocardiogram

Transthorasic EchocadiogramSince starting the Echocardiography program at the Academy of Ultrasound, LLC, we are constantly looking for new and improved reference materials.  The hope is to better explain, to our students and patients, what we as sonographers do and what the ultrasound test is.

One of the spots we frequent is the Family Practice Notebook (www.fpnotebook.com).  Recently we found a new outline formatted description of an Echocardiogram.  Its a great synopsis, complete with references to common terms and images. 

Below is their description.  Review it and leave any comments you might have.  We feel it will help with your understanding of the basic Echocardiography exam.

If you like it be sure to share this with your friends.



 Transthoracic Echocardiogram

See Also

    1. Transesophageal Echocardiogram
    2. Echocardiogram in Congestive Heart Failure
    3. Stress Echocardiogram
  • Background
    1. Use Phased-Array transducer (1-5 MHz)
      1. Faster frame rate to catch dynamic images throughout cardiac cycle
      2. Use cardiac preset
        1. Transducer marker corresponds to screen right (contrast with other presets where marker is on screen left)
    2. Most patients will have one adequate view to visualize heart function
      1. Quality of view is inversely proportional to body habitus (i.e. Obesity degrades the view)
      2. However, technique for a single view can be modified to visualize most structures
    3. Emergency Echocardiography (or Focused UltrasoundExamination) does not replace a complete Echocardiogram
      1. Emergency Echocardiogram is done to answer specific emergency related questions
  • Precautions
    1. Pericardial Effusion
      1. Features
        1. Pericardial Effusion will surround the heart and should be seen in multiple views
        2. Pericardial fluid moves in opposite direction as heart wall
        3. Cardiac Tamponade
          1. Right heart wall movement will be paradoxical rocking motion
            1. Right atrium collapse in systole (also occurs with hypovolemic shock)
            2. Right ventricular collapse in diastole
      2. Differential diagnosis (look-alikes on Echocardiogram, confirm in multiple views)
        1. Pericardial fat pad (moves with heart wall)
        2. Descending aorta
  • Indications: Emergency Echocardiogram
    1. Cardiac Arrest
      1. Cardiac standstill
        1. Distinguish from Ventricular Fibrillation appearance (shimmering appearance of ventricular wall)
        2. Distinguish from lung excursion with Positive Pressure Ventilation (stop PPV to visualize heart activity)
        3. Prolonged cardiac standstill may demonstrate congealed blood in ventricle
        4. Associated with little to no chance of survival (helps direct cessation of code)
          1. Blaivas (2001) Acad Emerg Med 8:616
      2. Identify reversible causes of PEA
        1. Cardiac Tamponade (Pericardial Effusion and right ventricular collapse in diastole)
        2. Hypovolemic shock (hyperdynamic heart with with small ventricular chamber)
        3. Pulmonary Embolism (new dilated right ventricular chamber)
        4. Myocardial Infarction (new wall motion abnormality, decreased contractility or EF)
    2. Shock or Hypotension
    3. Acute Dyspnea
    4. Trauma
      1. See FAST Exam
    5. Myocardial Infarction
    6. Ultrasound-Guided Pericardiocentesis
  • Views: General
    1. Parasternal Echocardiogram View
      1. Parasternal Long-Axis Echocardiogram View
      2. Parasternal Short-Axis Echocardiogram View
    2. Apical Echocardiogram View
    3. Subcostal Echocardiogram View
    4. Suprasternal Echocardiogram View
  • Views: Parasternal Long-Axis Echocardiogram View
    1. Improved window (bring heart closer to transducer and reduce rib shadowing)
      1. Patient positioned in left lateral decubitus position
      2. Start along sternal border near the 3rd interspace and check several interspaces inferiorly and laterally
    2. Transducer orientation
      1. Transducer 3-5 cm to the left of the left sternal border at the 3rd to 5th intercostal space
      2. Transducer indicator pointed towards patient’s right Shoulder (10:00 position)
    3. Images
      1. UltrasoundHeartPLAXAndPSAX.jpg
    4. Landmarks
      1. Right ventricle or right ventricular outflow tract
      2. Left ventricle, aortic valve and proximal aorta
      3. Mitral valve and left atrium
      4. Descending Aorta
    5. Conditions
      1. Visualizes the positions of the parasternal short axis cross sections (see below)
      2. Wall motion abnormalities (especially apex and septum)
      3. Valvular insufficiency (Mitral Regurgitation or Aortic Insufficiency) with color doppler
      4. Aortic root dilation (best imaged with same probe orientation but at the 3rd intercostal space)
      5. Left ventricular Systolic Dysfunction(CHF)
        1. Decreased contractility of left ventricle
          1. Normal
          2. Depressed or severely depressed
          3. Hyperdynamic
        2. Decreased ejection fraction
          1. Gross Estimate
            1. Estimate visually what percentage difference is seen between the left ventricle volume in systole and diastole
            2. M-mode compare end-systolic (ESD) and end-diastolic (EDD) diameters
          2. Linear calculation: Ultrasoundcalc package
            1. In M-Mode, measure end-diastolic (EDD) and end systolic (ESD) diameters
            2. Ejection fraction = 100 * (EDD^3 – ESD^3) / EDD^3
        3. Dilated left ventricle (end diastolic diameter >56 mm)
          1. Measure across widest point between septum and posterior wall
          2. Chordae tendinae may obscure true posterior wall
        4. E-point septal separation (EPSS) on M-Mode or cine
          1. Distance between the septum and the mitral valve leaflet when maximally open
          2. Normal is <8-10 mm (>20 mm is correlated with an EF<30%)
  • Views: Parasternal Short-Axis Echocardiogram View
    1. Transducer orientation (start)
      1. Transducer Rotated 90 degrees clockwise from Parasternal Long Axis View
      2. Transducer 3-5 cm to the left of the left sternal border at 3rd to 5th intercostal space
      3. Transducer indicator pointed towards patient’s left Shoulder (1:00 position)
    2. Transducer gradually tilted down heart axis to obtain 4 heart cross-sectional slices
      1. Aortic valve level
      2. Mitral valve level
      3. Mid-ventricle level
      4. Heart apex
    3. Images
      1. UltrasoundHeartPLAXAndPSAX.jpg
    4. Landmarks: Aortic valve level
      1. Right ventricular outflow tract
      2. Tricuspid valve, aortic valve (peace or mercedes sign when tri-leaflet) and pulmonic valve
      3. Right atrium, left atrium and pulmonary artery
    5. Landmarks: Mitral valve level
      1. Right ventricle
      2. Mitral valve (anterior and posterior leaflets appear as a fish mouth opening and closing)
    6. Landmarks: Mid-ventricle level
      1. Right ventricle
      2. Left ventricle (with trabeculations representing papillary muscles)
    7. Landmarks: Apical level
      1. Right ventricle (much smaller in size than left ventricle unless right ventricle dilated)
      2. Left ventricle
    8. Conditions
      1. Bicuspid aortic valve (Aortic valve level)
      2. Left ventricle wall motion abnormality (mid-ventricle level)
        1. Best view to see all left ventricle walls
  • Views: Apical Four Chamber Echocardiogram View
    1. Transducer orientation
      1. Transducer placed at PMI or approximately xiphoid level (6th intercostal space) in mid-clavicular line or nipple line
      2. Transducer indicator pointed towards patient’s left (3:00 position)
      3. Align energy toward right Shoulder along heart’s long axis
      4. Hand holding transducer is pushed with knuckles into the bed to get best angle through heart
    2. Landmarks: Four chamber heart view
      1. Right ventricle and left ventricle
      2. Tricuspid valve and mitral valve
      3. Right atrium, left atrium and descending aorta
    3. Conditions
      1. Pericardial Effusion
      2. Apical thrombus (decrease depth to see, apex is closest to probe in this location)
      3. Systolic Dysfunction
      4. Wall motion abnormalities
  • Views: Subcostal Echocardiogram View (or subxiphoid view)
    1. See FAST Exam
    2. Pearls to improve view window
      1. Consider starting this view longitudinally with indicator at 12:00 to identify left lobe of liver and angle through heart
      2. View improves with the patient taking a deep inspiration
    3. Transducer orientation
      1. Hold transducer over the top (more at the base of probe) to allow for a more shallow angle
      2. Push the transducer down (posteriorly) to drop below (deep) to the xiphoid process
      3. Transducer placed sub-xiphoid (by 1-2 cm) in superior epigastrium
      4. Transducer indicator pointed towards patient’s right (9-10:00 position) with energy toward left Shoulder
    4. Landmarks
      1. Four chamber heart view
      2. Increase angle of approach (aiming more posterior) if aorta is seen in the four chamber view
    5. Conditions
      1. Pericardial Effusion
      2. Systolic Dysfunction
      3. Wall motion abnormalities
  • Views: Subcostal Longitudinal (volume status view)
    1. Pearls to improve view window
      1. View improves with the patient taking a deep inspiration
    2. Transducer orientation
      1. Transducer placed right lateral to sub-xiphoid
      2. Transducer indicator pointed towards 12:00 with energy toward left atrium
    3. Landmarks
      1. Inferior vena cava
      2. Right atrium
    4. Conditions
      1. Volume depleted (e.g. Hemorrhagic Shock, dehydration)
      2. Volume overload (e.g. Congestive Heart Failure)
    5. Interpretation: Volume status based on IVC alone
      1. Inferior vena cava (IVC) is normally 1.5 to 2.5 cm in diameter (measured 3 cm from atrium)
        1. IVC <1.5 cm suggests volume depletion
        2. IVC >2.5 cm suggests volume overload
      2. Inferior vena cava (IVC) normally collapses more than 50% with inspiration or sniffing
        1. Total collapse suggests volume depletion
        2. Collapse <50% suggests volume overload
      3. Correlation between RA pressure (CVP) and IVC appearance
        1. CVP 0-5 cm: IVC totally collapses on inspiration and is <1.5 cm in diameter
        2. CVP 5-10 cm: IVC collapses >50% on inspiration and is 1.5 to 2.5 cm in diameter
        3. CVP 11-15 cm: IVC collapses <50% on inspiration and is 1.5 to 2.5 cm in diameter
        4. CVP 16-20 cm: IVC collapses <50% on inspiration and is >2.5 cm in diameter
        5. CVP >20 cm: No change in IVC on inspiration and is >2.5 cm in diameter
    6. Interpretation: Volume status by Caval Aorta Index
      1. Step 1: Measure maximal internal IVC anteroposterior diameter (in M Mode)
        1. Subxiphoid level in longitudinal axis
        2. Measure just caudal to confluence of hepatic veins
      2. Step 2: Measure maximal internal aorta anteroposterior diameter (in M Mode)
        1. Subxiphoid region in longitudinal axis
        2. Measure just to the left of the IVC
      3. Step 3: Calculate the Caval Aorta Index as IVC/Ao
        1. CVP <7 cm H2O: Caval Aorta Index of 0.72 (+/- 0.09)
        2. CVP 8-12 cm H2O: Caval Aorta Index of 1.23 (+/- 0.12)
        3. CVP >13 cm H2O: Caval Aorta Index of 1.59 (+/- 0.05)
      4. Reference
        1. Sridhar (2012) ISRN Emergency
  • Views: Suprasternal Echocardiogram View
    1. Transducer orientation
      1. Transducer placed in suprasternal notch
      2. Transducer indicator pointed towards 9:00
      3. Align energy inferiorly (towards feet) until arch comes into view
      4. Rotate transducer clockwise until arch is in full view
    2. Landmarks
      1. Brachiocephalic artery, Left Carotid Artery, Left subclavian artery
      2. Aortic arch
      3. Right pulmonary artery
      4. Left atrium
    3. Conditions
      1. Aortic Dissection
      2. Aortic aneurysm
  • Resources
    1. Sub-xiphoid View Video (SonoSite)
      1. http://www.youtube.com/watch?v=1UJ6RodOSTw
    2. Apical 4-Chamber View Video (SonoSite)
      1. http://www.youtube.com/watch?v=_eHZz-OCc_M
    3. Parasternal Long Axis View Video (Sonosite)
      1. http://www.youtube.com/watch?v=4qerzEW_ASU
    4. Parasternal Short Axis View Video (SonoSite)
      1. http://www.youtube.com/watch?v=EaLuCBXXINg
    5. Suprasternal Notch View Video (Sonosite)
      1. http://www.youtube.com/watch?v=Mkc6tUVRgKo
    6. Inferior Vena Cava UltrasoundVideo (SonoSite)
      1. http://www.youtube.com/watch?v=ci9W4MvyMHI
    7. Echocardiographer
      1. http://echocardiographer.org/
  • References
    1. Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete’s Beach
    2. Noble (2011) Emergency and Critical Care Ultrasound, Cambridge University Press, New York, p. 61-88
    3. Reardon (2011) Pocket Atlas Emergency Ultrasound, McGraw Hill, New York, p. 61-106

By John Sheldon

What is an Echocardiogram?

Echocardiography HeartToday I was searching the web for interesting topics in the field of Echocardiography and Ultrasound in general.  This process started me thinking; We speak about echocardiograms and other Ultrasound studies all the time, but do our readers always know what the exams are?

One of the articles I found, does a pretty good job of explaining exactly what an Echocardiogram is.  I have decided to share this with my readers.

Here is an excerpt from the article:

What is an echocardiogram?
An echocardiogram is a non-invasive diagnostic test performed to evaluate the heart’s function. While the echocardiogram is being done, both you and your doctor will be able to watch your heart, as it beats, on a small monitor. It is often performed on pediatric cardiac patients.
What kinds of things can an echocardiogram find?
An echocardiogram is able to monitor the performance of the valves. It can help to diagnose structural abnormalities in the heart wall, valves, and blood vessels. It can detect tumors, clots or pericardial effusions (abnormal fluid collection around the heart). It is sometimes used after a heart attack to evaluate the cardiac wall motion and function. The most frequent use of an echocardiogram is for diagnosing or monitoring congenital heart disease, cardiomyopathies or aneurysms.

 The link to the full article is http://www.cardioassoc.org/?p=257.  This is worth reading.

If you enjoy this post consider sharing with your favorite sites.



Cardiovascular (Echocardiography) and Vascular Sonographers: Updated salary and job information as of 2010 data

Cardiovascular exam

We are all affected by today’s unpredictable economy.  This fact makes it a bit difficult for someone to determine what career path to choose or to even change your existing career path.  So, we are now forced to research longer and deeper than we would have before in order to make the best decision when deciding on what we want to do with our life.  There are a few important facts when considering a career path or change which include work environment, salary, and the predicted future of the chosen field.

When considering sonography, you must first decide which modality would be the best “fit” for you.  Let us take a look at two of the modalities.  For example:   Cardiovascular (Echocardiography) and Vascular Sonography.

Cardiovascular, sometimes referred to as “Echocardiography,” is where the technician uses diagnostic imaging to assist the physicians in the diagnoses of cardiac (heart)  ailments in patients.

Vascular sonography is where the technician uses diagnostic imaging to assist the physicians in the diagnoses of peripheral (blood vessel) vascular ailments in patients such as blood clots.

The work environment for both Cardiovascular and Vascular sonographers are similar.  These technicians usually work in a healthcare facility such as a hospital, clinic, and/or a physician’s office.  Now, another possibility is to work for a “mobile” service where the sonographer is employed by the “mobile” company that is contracted by a physician (physician’s office) who schedules regular patient appointments on a certain day(s) during the month, for example.

As of May 2010, according to the U.S. Bureau of Labor Statistics, the average starting salary for cardiovascular and vascular technicians is around $49,410.00 per year.  This equates to about $23.75/hour.  The job outlook over the next ten years in this field is expected to increase approximately 29%, which is much faster than the average.  Basically, the increase is due to the evolution of technology allowing medical facilities to replace more invasive procedures with less costly ones.

Patient comfort is important during exam.

Even though hosptials are the primary employers of cardiovascular and vascular technicians, it is predicted that employment will grow more rapidly in physicians’ offices as well as in diagnostic laboratories due to the shift toward outpatient care whenever possible.

In summary, it will also be important to make yourself as “marketable” as possible.
In order to ensure your marketability as a potential employee, it makes sense to be as prepared as possible.  In the world of diagnostic medical imaging, this includes – not limited to- being registered in more than one ultrasound modality.  For example, it is becoming more and more familiar to hear that an employer is looking for a “dual” registered candidate.  This may mean holding dual registries such ash General and Vascular, or Echocardiography/Cardiovascular and Vascular, etc.  Some employers will interview a registered candidate witht the requirement being that the person will sit for the other registry within  six months to one year.  This scenario is becoming more and more common.
With the predicted employment of 63,900 technicians by the year 2020 as Cardiovascular and Vascular technicians, it is imperative to be ready.
Contact us at (866) 867-2824 for information on our next online “cross-over” course in Cardiovascular/Echocardiography and Vascular ultrasound.  Our courses begin on the 1st of each month.

Ultrasound Specialties and Modalities Available

One of the most common dilemnas a potential ultrasound student faces is which modality to consider.  Most people considering ultrasound as a possible career choice are unaware of the different areas of specialization available to them.  Thus, the main focus of this blog post is to educate the public on the possibilities in the field of sonography.  In an effort to keep this particular post as short and concise as possible, as to not be boring, I will publish a series of  THREE blog posts on the subject of the specialties and modalities available.  So, be sure to visit our blog for the upcoming posts.

First of all, it is not necessary to become a Diagnostic Medical Sonographer (DMS) prior to choosing a specialty.  There seems to be a misconception that one must receive General Ultrasound training before completing the training for a specialized area; this is not so.  However, it is the decision of the trainee as to the length of training willing to persue.  With that in mind, it is possible to seek – for example, training in Echocardiography without receiving certification in another modality, first.

General Ultrasound imaging

The areas of specialization being discussed in this post are:


  1. Abdominal and Small Parts – these sonographers produce images of organs or organ systems within the abdominal cavity of the patient. The abdominal cavity includes: liver, biliary system, spleen, pancreas, urinary system, breast, thyroid, great vessels, and male reproductive system. The images that are produced assist physicians in diagnosing and treating certain diseases and disorders.
  2. Obstetrics and Gynecology (OB/GYN) – the female reproductive system is the focus of the images made by these sonographers. Naturally, the most common association of ultrasound imaging is that of a pregnant woman where the doctor monitors the growth and health of the fetus.
  3. Breast Sonography – one of the tools used to fight breast cancer. Tumors are often detected by using ultrasound images of the breast tissue and blood supply. Mammography is often coupled with mammography.
  4. Neurosonography – sonographers produce ultrasound images of the nervous system which includes the brain. It is common for Neurosonographers to work in neonatal care which includes diagnosing and studying the conditions of the neurological and nervous system of premature infants.


It is a fact that sonographers who are registered in more than one modality strengthen their marketability; therefore, resulting in increased salaries.  While working at just one facility – such as a hospital- may be attractive to some, it is possible for sonographers to seek employment with an additional facility – such as a private practice – using another specialty. For example, if you are employed as a full-time Echo Tech at a hospital and are also registered as a  Vascular Tech, you may choose to work for a private practice on a part-time basis or even weekend “call” basis.  This is just one example of using multiple modality certifications to advance career and earnings potential.

The credentials associated with the above modalities (others will be mentioned in upcoming series posts) provided by the American Registry for Diagnostic Medical Sonography (ARDMS) are:

  • RDMS – Registered Diagnostic Medical Sonographer


For the next modality to be discussed in this series, be sure to visit our blog next week.

(Please view our previous posts such as “The Truth: Accredited v. Non-accredited” )

www.academyofultrasound.com  For information regarding online ultrasound program, email: info@academyofultrasound.com

Updated for Academy of Ultrasound, LLC

Good Morning!

 I would like to take this opportunity to update those who may not already be aware of the following information.  Recently, a member of the Academy of Ultrasound staff was asked to join the review committee team for an accreditation visit to another Ultrasound school located in Los Angeles, CA.  We are honored to be participating in such an endeavor.  This is a precursor to finalizing our National Accreditation as well as  positioning the Academy one step closer to securing its CAAHEP accreditation.  Once finalized, the option of utilizing Federal Student Financial Aid should soon follow.

For any questions or request for more information on online Ultrasound/Sonography training, contact us at info@academyofultrasound.com or phone 866-867-2824.

Thank you, once again, for following our blog.

New Healthcare Reform’s affect on Allied Health Professions

Recently, With Obama’s Healthcare Reform Bill being signed into law, there are concerns over what this means  for the Allied Health Profession.   According to the Bureau of Labor Statistics, the healthcare industry will be providing the greatest number of jobs over the next ten years. 

Now that the “baby boomers” are reaching their “Golden Years,” the demand for trained healthcare professionals will be at its highest.  This influx in the older population results in an increase in other Allied Health areas such as Diagnostic Imaging, Medical records, and IT jobs that are most critical to the system.

According to SDMS News Wave,January 2010, there will be some fundamental changes occurring for the American Healthcare system.  These change include:

  1. Strong concern for Cost-effective diagnostic technology
  2. Renewed interest in the “least invasive” approach to diagnostic medicine
  3. Preferences for the most clinically efficacious, yet cost-effective diagnostic tools


With the aforementioned issues being a driving force behind reform(as cited by SDMS News Wave, January 2010) sonography acknowledges its unparalleled position within the field of medical imaging to take advantage of its fundamental aspects:

  • Clinical efficacy
  • Cost effectiveness
  • Non-ionizing
  • Real-time adjustability

Sonographers are most likely to benefit from being at the ‘right place, at the right time’ as the healthcare changes take hold within the healthcare system and the medical community.

According to ExploreHealthCareers.org, the health care industry has added more than 500,000 jobs since the start of the recession…

The healthcare support industry (such as physical therapists, physical therapists assistants, medical social workers, and home health aides) will experience a 48% growth…

Health care is forecasted to remain a key source of job growth, especially in areas such as medical records and health information technicians, registered nurses, and clinical laboratory technicians…..

Health care dominates as the fastest growing field…

…All good news for those interested in a health care career!

We will keep continue monitoring the information available on this issue as becomes accessible.

Please, feel free to comment on ANY news you may have about the impact of the new bill on Allied Health careers and Thank you for your support by following this blog.