Echocardiography (Echo)

What is an echocardiogram?

An echocardiogram (also called echo, transthoracic echocardiogram or TTE, exercise or stress echocardiogram, dobutamine stress echocardiogram or DSA, or transesophageal echocardiogram or TEE) is a noninvasive (the skin is not pierced) procedure used to assess the heart's function and structures. A transducer (like a microphone) sends out ultrasonic sound waves at a frequency too high to be heard. When the transducer is placed on your chest at certain locations and angles, the ultrasonic sound waves move through the skin and other body tissues to the heart tissues, where the waves echo off of the heart structures. The transducer picks up the reflected waves and sends them to a computer. The computer interprets the echoes into an image of the heart walls and valves.

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An echocardiogram can utilize one or more of four special types of echocardiography:

M-Mode echocardiography: This is the simplest type of echocardiography. It produces an image that is similar to a line tracing rather than an actual picture of heart structures. M-mode echo is useful for measuring heart structures, such as the heart's pumping chambers, the size of the heart itself, and the thickness of the heart walls.
Doppler echocardiography: This Doppler technique is used to measure and assess the flow of blood through the heart's chambers and valves. The amount of blood pumped out with each beat is an indication of the heart's functioning. Also, Doppler can detect abnormal blood flow within the heart, which can indicate a problem with one or more of the heart's four valves or with the heart's walls.
Color Doppler: Color Doppler is an enhanced form of Doppler echocardiography. With color Doppler, different colors are used to designate the direction of blood flow. This simplifies the interpretation of the Doppler technique.
2-D (2-dimensional) echocardiography: This technique is used to "see" the actual structures and motion of the heart structures. A 2-D echo view appears cone-shaped on the monitor, and the real-time motion of the heart's structures can be observed. This enables the physician to see the various heart structures at work and evaluate them.

Why is an echo done?

There are several diseases of the heart that may be detected by echocardiography, including the following:

atherosclerosis (coronary artery disease) - a gradual clogging of the arteries over many years by fatty materials and other substances in the blood stream.
aneurysm - a dilation of a part of the heart muscle or the aorta (the large artery which carries oxygenated blood out of the heart to the rest of the body) which may cause a weakness of the tissue at the site of the aneurysm. In extreme cases, the aneurysm may rupture, which is an emergency situation, due to rapid blood loss out of the blood vessels.
cardiomyopathy - an enlargement of the heart, due to thickening or weakening of the heart muscle.
congenital heart disease - congenital heart disease refers to one or more of several conditions which are present at birth ("birth defects"). Some congenital heart conditions include:
- ventricular septal defect (VSD)
  In this condition, a hole occurs between the two lower chambers of the heart. Because of this hole, blood from the left ventricle flows back into the right ventricle, due to higher pressure in the left ventricle. This causes an extra volume of blood to be pumped into the lungs by the right ventricle, which can create congestion in the lungs.
- transposition of the great vessels
  In this condition, the outflow tracts of the aorta and the pulmonary artery are switched during fetal development. This means that unoxygenated blood flows out to the body through the pulmonary artery and oxygenated blood flows back into the lungs through the aorta. By itself, this condition cannot sustain life after birth. However, there are usually accompanying defects that permit some oxygenated blood to get out to the body tissues.
- tricuspid atresia
  In this condition, the tricuspid valve between the right atrium and right ventricle is missing. By itself, this would mean that no blood can be pumped into the lungs to receive oxygen; however, there are usually accompanying defects that allow some blood to go to the lungs.
congestive heart failure - a condition in which the heart muscle has become weakened to an extent that blood cannot be pumped efficiently, thus causing buildup (congestion) in the blood vessels, lungs, feet, ankles, and other parts of the body.
pericarditis - an inflammation of the sac (thin covering) that surrounds the heart.
valvular heart disease - one or more of the heart's four valves becomes defective, or may be congenitally malformed.

An echocardiogram may be done to further evaluate signs or symptoms of these conditions.

How is an echocardiogram done?

A basic echocardiogram may be done in the physician's office, a clinic, or in the hospital. For the procedure, you will remove your clothing from the waist up. Privacy will be ensured by using drapes across the chest and limiting access into the procedure room during the test. You will lie on your left side on a table or bed, but may be asked to change position during the procedure. EKG leads may be attached to your chest, so that the echo images can be compared to the EKG tracing during and after the procedure. The echocardiography technician will apply warmed gel to your chest. Then he/she will position the transducer on your chest and use a small amount of pressure to obtain the desired image. The technician will move the transducer around on your chest so that all areas and structures of your heart can be observed. During the test, the different echo techniques described above (M-mode, 2-D, Doppler, and color Doppler) may be used. You will not be aware of the different techniques except that during the Doppler or color Doppler, you may hear a "whoosh-whoosh" sound. This whooshing sound is your blood moving through the heart.

Once all the images have been taken, the technician will wipe the gel from your chest, remove the EKG electrode pads, and assist you to dress, if necessary. Once the procedure has been completed, you will be able to leave and return to your previous activities, unless your physician instructs you differently. The procedure usually takes about 30-45 minutes to perform. However, factors such as schedule delays, emergencies, and other factors may delay the start of your procedure or prolong the length of it.

There are other types of echo procedures. These procedures are described below.

exercise (stress) echocardiogram
The initial portion of an exercise echo is similar to the basic echo procedure described above. After the resting echo images have been obtained, you will begin to exercise on a treadmill or stationary bicycle. You will exercise until a target heart rate (determined by the physician based on your age and physical condition) has been reached, or until you are unable to continue exercising due to chest pain, leg pain, dizziness, severe shortness of breath, or severe fatigue.

Once the target heart rate has been reached, you will continue to exercise for a minute or so more. Then you will lie down on the table or bed and the echo procedure will be repeated. The physician will compare the resting echo with the one done immediately after exercise. Once all the images have been taken, the technician will wipe the gel from your chest, remove the EKG electrode pads, and assist you to dress, if necessary.

Once the procedure has been completed, you will be able to leave and return to your previous activities, unless your physician instructs you differently. The procedure usually takes about 45 minutes to an hour to perform. However, factors such as schedule delays, emergencies, and other factors may delay the start of your procedure or prolong the length of it.

Some reasons for having an exercise echocardiography include, but are not limited, the following:
- to assess limits for safe exercise in patients who are entering a cardiac rehabilitation program and/or those who are recovering from a cardiac event such as heart attack or heart surgery
- to assess leg pain with exercise (also called intermittent claudication) in patients with suspected occlusion in the legs' circulatory system
- to assess blood pressure reaction during exercise
- to assess stress or exercise tolerance in patients with known or suspected coronary artery disease
dobutamine stress echocardiography
This procedure is done as a substitute for an exercise echo, because some people may be unable to exercise on a treadmill or stationary bicycle due to conditions such as:
- recent heart attack
- severe hypertension (high blood pressure)
- severe arrhythmias (heart rate is too fast, too slow, or too irregular)
- severe leg pain with exercise due to poor blood flow in the legs
- severe asthma, emphysema, or chronic obstructive pulmonary disease (COPD)
- aneurysm
- pericarditis
If any of the above reasons, or other reasons, are present which prevent a patient from exercising on a treadmill or bicycle, it is possible to mimic exercise by injecting an intravenous (IV) medication called dobutamine. Dobutamine causes the heart to beat faster as it does during exercise.

The preparation for the DSE procedure is similar to that of the basic echo described above. In addition, an IV line will be started in your hand or arm, and a blood pressure cuff will be placed on your arm. A baseline assessment of your heart rate and blood pressure will be done.

The echocardiography technician will apply warmed gel to your chest. Then he/she will position the transducer on your chest and use a small amount of pressure to obtain the desired image. The dobutamine infusion will begin at a rate determined by your weight. The rate of the infusion will be increased every three minutes until you have reached your target heart rate (determined by the physician based on your age and physical condition) or until the maximum dose of dobutamine has been reached. After the dobutamine is started and after each increase in the dobutamine rate, your blood pressure will be checked, an EKG tracing will be made, and echo images will be obtained. The technician will move the transducer around on your chest so that all areas and structures of your heart can be observed. During the test, the different echo techniques described above (M-mode, 2-D, Doppler, and color Doppler) may be used.

You will not be aware of the different techniques except that during the Doppler or color Doppler, you may hear a "whoosh-whoosh" sound. This whooshing sound is your blood moving through the heart.

Once your have reached your target heart rate or the maximum amount of the dobutamine, the medication will be stopped. Your heart rate, blood pressure, EKG, and echo will continue to be monitored for 10-15 minutes until they have returned to the baseline state, or close to it. Once all the images have been taken, the technician will wipe the gel from your chest, remove the EKG electrode pads, take out the IV line, and assist you to dress, if necessary.

Once the procedure has been completed, you will be able to leave and return to your previous activities, unless your physician instructs you differently. A DSE usually takes about 1-1½ hours to perform. However, factors such as schedule delays, emergencies, and other factors may delay the start of your procedure or prolong the length of it.

Some reasons for having a dobutamine stress echo include, but are not limited to, the following:
- to assess the heart's function and structure
- to assess limits for safe exercise in patients who are entering a cardiac rehabilitation program and/or those who are recovering from a cardiac event such as heart attack or heart surgery
- to assess blood pressure reaction during stress testing
- to assess stress or exercise tolerance in patients with known or suspected coronary artery disease
- to assess cardiac status in patients who are about to undergo surgery
transesophageal echocardiography (TEE)
Transesophageal echocardiography is done by inserting a probe down your throat (esophagus) to the level of the heart. The TEE transducer works the same as the transducer used for the other procedures. However, a clearer image can be obtained, because the sound waves do not have to pass through skin, muscle, or bone tissue. Certain conditions of the heart, such as mitral valve disease, blood clots or masses inside the heart, dissection (tear) of the lining of the aorta (the artery which carries oxygenated blood from the heart to the body), and implanted prosthetic (artificial) heart valves are better visualized and assessed with TEE.

TEE may also be used during surgery to assess the cardiac status of patients with known cardiac disease who are undergoing noncardiac procedures, and during heart surgery to evaluate the effects of surgical intervention to the heart, such as bypass surgery or valve repair or replacement.

For a TEE procedure, you are taken to a special area with echocardiography and EKG equipment. You will undress from the waist up, and EKG pads will be attached to your chest. You will be given a gown to wear. You will lie on a table or bed for the procedure. An intravenous (IV) line is placed in your hand or arm, so that sedative medication can be given. Sedatives are given to help you relax, but you will remain awake enough to assist in the procedure by swallowing as the TEE probe is passed down your throat. A numbing medication will be sprayed in the back of your throat to make passage of the TEE probe more comfortable. If you have an artificial heart valve, certain congenital conditions, or a history of endocarditis (infection of heart valves), you may be given a dose of IV antibiotics an hour or so prior to the procedure. The echo images are obtained from various angles, as the physician can position the TEE probe remotely. Once all the necessary images have been obtained, the TEE probe will be removed from your throat. You will continue to be monitored in a recovery area until your gag reflex returns and you can swallow adequately enough to take fluids without choking and until you are alert enough to leave. Your heart rate, EKG, blood pressure, and breathing rate will be monitored. Your oxygen level may also be monitored by a probe placed on the tip of a finger or ear lobe. You will need to make arrangements for someone to drive you home after the procedure, as you will not be allowed to drive after having IV sedation.

A TEE usually takes about 2 hours to perform. However, the length of the procedure can be affected by factors such as schedule delays, emergencies, and other factors which may delay the start of your procedure or prolong the length of it.

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