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both narrow- and wide-angled acquisition modes, which in turn has an impact on
the size of the pyramidal volume. Data are stored digitally on CD-ROM and may be
transferred to an off-line computer for quantitative purposes.
The left ventricle (apical four-, three-, and two-chamber views) is usually
acquired from the apical window using wide-angled acquisition (Figure 10.22).
Images may be displayed using either orthogonal long-axis views or multiple
short-axis views, obtained at the level of the left ventricular apex, papillary muscles,
and the base (Figure 10.22, bottom row). For example, when slicing the heart
orthogonally in a four-chamber view, the septal and lateral walls together with the
entire surface ofthe anterioror posteriorwall are visualized (Figure 10.22, top row).
Likewise, in a two-chamber view, the anterior and inferior walls are imaged in con-
junction with the entire surface of the septum or lateral walls, depending on the
orthogonal cut used (Figure 10.22, middle row). The right ventricle can also be
assessed from a traditional four chamber. In contrast to 2-D echocardiography, 3-D
echocardiography does not rely on geometric assumptions to calculate left ventricu-
lar volumes. This constitutes a real advantage in ventricles with odd shapes and wall
motion abnormalities [86]. Similarly, the unique geometrical shape of the right ven-
tricle has precluded accurate quantification using traditional echocardiographic
methods.
Transthoracic 3-D echocardiography has the potential to overcome these limita-
tions, resulting in accurate measurements of right ventricular size and function.
Multiple studies have found 3-D calculated left ventricular volumes, ejection frac-
tions, and left ventricular mass values to be comparable to those obtained with
274 Echocardiography: A Tool for LVSD Identification
Base
Two chamber
Septal wall Lateral wall
Four chamber
Anterior wall
Posterior wall
Mid
Apex
Figure 10.22 Wide-angled scan of the left ventricle sliced using multiple cut planes.
nuclear imaging and MRI. However, because gated acquisition methods including
free-hand scanning are tedious, time consuming, and relatively nonportable, calcu-
lations of left ventricular ejection fractions from 3-D reconstructions have not been
incorporated into routine echocardiographic studies. Additional disadvantages of
the previously used 3-D methodologies include these: (1) datasets were acquired
over multiple heart cycles; (2) data processing was slow because of the limitations of
computer technology; (3) calculation of left ventricular volumes was performed on
an off-line system, which requires tedious manual tracing of endocardial borders;
and (4) the left ventricle was displayed using a static wire frame, which failed to
provide anatomic information.
Quantification of left ventricular volumes and mass using real-time 3-D
echocardiography is usually performed from using various apical wide-angled
acquisition methods. Because a dataset comprises the entire left ventricular volume,
multiple slices can be obtained from the base to the apex of the heart to evaluate
wall motion. This acquisition can be combined with the use of an contrast infusion,
particularly in patients who have a difficult acoustic window in whom it might be of
benefit to improve the delineation of the endocardial border.
The 3-D volume dataset is then automatically divided intoa number (that is, n =
8) of predetermined equiangled longitudinal slices through the apex (Figure 10.23,
10.5 Real-Time 3-D Echocardiography 275
B
A
C
D
E
F
Figure 10.23 Panel A depicts the pyramidal volume of data divided automatically into eight
equiangled longitudinal slices through the apex. Panels B and C depict the automated border
detection algorithm used to track endocardial borders throughout the cardiac cycle. A dynamic
ventricular cast is automatically displayed as a result of the endocardial borders and surface recon
-
struction (panel D). Global volumes and ejection fraction are displayed in panel E. Regional vol
-
umes of all 16 segments are shown in panel F.
panel A). Themidpoint ofthe mitral valve annulus, apex, and aortic valve are identi-
fied as landmarks. In each of the longitudinal slices, an automated border detection
algorithm is then used to track endocardial borders throughout the cardiac cycle
(Figure 10.23, panels B and C) to obtain a dynamic cast of the left ventricle, as well
as instantaneous global and regional left ventricular volumes versus time curves
(Figure 10.23, panels D–F). This method of data analysis is semiautomated. In pre-
liminary work, the volumes obtained with this method compare favorably with
those obtained with cardiac MRI.
An alternative method of calculating ventricular volumes from a real-time 3-D
cardiac volume dataset is to use the disc summation method, which has been well
validated in thepast (Figure10.24). With this method, multiple short-axis cutplanes
are obtained from base to apex using a predefined distance interval. In each
short-axis slice, endocardial borders at end systole and end diastole are traced and
the summations of these volumes at end systole and end diastole are used to calcu-
late left ventricular ejection fraction.
276 Echocardiography: A Tool for LVSD Identification
A
B
C
D
Figure 10.24 The disc summation method is an alternative method for calculating left ventricular
volume and ejection fraction. The left ventricle is placed in a longitudinal position (panels A and
B). With predefined distance intervals, multiple short-axis cut planes are derived and endocardial
borders traced in all end-systolic and end-diastolic frames (panel C). The summation of the vol
-
umes of each slice results in the left ventricular volumes illustrated in panel D.
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278 Echocardiography: A Tool for LVSD Identification
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280 Echocardiography: A Tool for LVSD Identification
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10.5 Real-Time 3-D Echocardiography 281
CHAPTER 11
Diagnosis of Heart by
Phonocardiography
Manivannan Jayapalan
11.1 Introduction
Blood flow through the human heart gives rise to vibrations and sounds that can be
acquired from the surface of the chest. These sounds contain information regarding
the condition of the heart. Two principal methods are used to investigate heart
sounds: cardiac auscultation and phonocardiography. The act of listening to sounds
produced by body vessels and organs is called auscultation. The recordings of these
sounds produced in the heart are called phonocardiograms, and the device used to
record then is called a phonocardiograph. A typical phonocardiograph and a
recording are shown in Figure 11.1.
Software-aided heart sound analysis has several advantages compared to tradi-
tional cardiac auscultation using a stethoscope. The most obvious one is the
improved reliability of diagnoses. In traditional cardiac auscultation, murmurs at
very low frequencies may not be heard; in addition, classification of heart murmurs
into innocent and pathological is strongly dependent on the listener’s experience
and training. Incontrast, ina phonocardiogram, even the low-frequency sounds can
be picked by using an improved performance sensor, and they can be better visual-
ized in a spectrogram representation. Another significant advantage is that heart
sounds can be saved as a part ofthe documentation,such as patient information and
diagnosis. When necessary, this can easily be sent as an e-mail attachment to a car-
diology specialist, who can analyze the results. Today and almost certainly even
more so in the future, the ability to exchange documents electronically is a time and
cost-efficient way to conduct a cardiologic consultation when necessary. Based on
these strong advantages, this chapter first discusses the origin of heart sounds and
the ways in which they can be captured. That discussion is followed by an explana-
tion of the different possible techniques by which heart sounds can be analyzed to
aid in diagnosis.
283