Category Archives: Cardiovascular

Seeing the Heart in Motion: A History of Echocardiography

Posted on by
Reply

Ultrasound has become one of the most important tools for examining the heart, but its role in cardiology developed gradually over decades of innovation. What we now know as echocardiography, ultrasound imaging of the heart, has a history rooted in physics, wartime technology, and creative medical problem-solving.

The story begins in the early 20th century with the discovery of ultrasound’s physical properties. Scientists learned that high-frequency sound waves could travel through materials and bounce back when they encountered different surfaces. This principle was first put to practical use in sonar systems during World War II to detect submarines. After the war, physicians began to wonder whether similar sound waves could be used to “see” inside the human body without surgery or radiation.

In the 1950s, this idea reached cardiology. Swedish physician Inge Edler and physicist Hellmuth Hertz were among the first to apply ultrasound to the heart. They adapted industrial ultrasound equipment to record moving structures inside the chest. Instead of producing an image as we know it today, their system created a one-dimensional tracing that showed how heart structures moved over time. This technique, later called M-mode echocardiography, allowed doctors to measure heart chamber size and observe valve motion for the first time in a living patient.

M-mode ultrasound showing echo pattern records of the motion of the anterior leaflet of the mitral valve (left, normal; right, stenosis).
M-mode ultrasound showing echo pattern records of the motion of the anterior leaflet of the mitral valve (left, normal; right, stenosis).

By the 1960s and 1970s, ultrasound technology improved significantly. Two-dimensional imaging replaced simple motion tracings, allowing clinicians to see cross-sectional pictures of the beating heart. These real-time images made it possible to visualize heart chambers, valves, and major blood vessels in motion. Doctors could now assess heart muscle thickness, pumping function, and structural abnormalities without opening the chest or exposing patients to X-rays.

Another major breakthrough came with Doppler ultrasound, which describes how sound waves change when reflecting off moving objects. Doppler techniques made it possible to measure blood flow. Applied to the heart, Doppler ultrasound allowed physicians to determine the speed and direction of blood moving through valves and chambers. This innovation transformed echocardiography from a purely anatomical tool into one that could evaluate function. Conditions such as valve narrowing, valve leakage, and abnormal blood flow patterns could now be identified and measured.

A longitudinal color Doppler image of the carotid artery.
A longitudinal color Doppler image of the carotid artery.

In the 1980s and 1990s, echocardiography became more portable and widely available. Machines grew smaller and more powerful, making it easier to use ultrasound at the bedside, in emergency rooms, and in outpatient clinics. Transesophageal echocardiography, in which a small ultrasound probe is passed into the esophagus, provided clearer images of certain heart structures by placing the transducer closer to the heart. This method proved especially useful for detecting clots, infections of the heart valves, and subtle structural defects.

As computing power increased, digital imaging and advanced processing expanded what ultrasound could show. Three-dimensional echocardiography offered more realistic views of heart anatomy, improving the assessment of valve disease and congenital heart defects. Strain imaging and other advanced techniques made it possible to evaluate how heart muscle fibers deform during each beat, helping detect early signs of disease before major symptoms appeared.

Today, ultrasound is a cornerstone of cardiac care. It is used to diagnose heart failure, guide procedures, monitor treatment, and screen for inherited or structural heart problems. Its advantages, including being noninvasive, radiation-free, and relatively affordable, have made it indispensable across healthcare settings. From large hospitals to small clinics, echocardiography provides critical information that once required far more invasive tests.

The history of ultrasound in heart imaging reflects a broader trend in medicine: the move toward safer, faster, and more informative diagnostic tools. What began as an adaptation of wartime sonar has evolved into a sophisticated technology that reveals the heart in motion, beat by beat. As innovation continues, ultrasound will likely play an even greater role in understanding and protecting one of the body’s most vital organs.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Ultrasound’s Hidden Superpowers and Why We Celebrate Them Every October

Posted on by
Reply

Every October, the medical imaging community comes together to observe Medical Ultrasound Awareness Month (MUAM), a period dedicated to raising public understanding of the ultrasound’s vital role in healthcare. Sponsored by organizations such as the American Institute of Ultrasound in Medicine (AIUM), the American Registry of Diagnostic Medical Sonographers (ARDMS), the American Society of Echocardiography (ASE), Cardiovascular Credentialing International (CCI), the Society of Diagnostic Medical Sonography (SDMS), and the Society for Vascular Ultrasound (SVU), MUAM seeks to dispel the common misconception that ultrasound is mainly for pregnancy and to shine a light on its many other life-changing uses.

While many people immediately think of fetal imaging when they hear “ultrasound,” that’s only one of many applications. In fact, ultrasound helps patients at every stage of life, from newborns to seniors, across numerous medical fields. MUAM is a perfect time to celebrate the often-unseen breadth of ultrasound and the professionals who use it.

Why a Special Month for Ultrasound?

Ultrasound is safe, widely available, and cost-effective. Because it doesn’t rely on ionizing radiation (as with X-rays or CT scans), it offers a gentler imaging option, particularly for soft tissues.

The purpose of MUAM is to encourage professionals to educate patients, colleagues, and the public about how ultrasound supports diagnosis, monitoring, and treatment across a diversity of conditions.

Beyond Babies: Diverse Applications of Medical Ultrasound

Here’s a look at just a few of the many ways ultrasound is used outside obstetrics:

1. Cardiac / Echocardiography

  • Ultrasound is widely used to visualize the heart’s structure and function, assess valve integrity, detect fluid around the heart (pericardial effusion), and monitor things like left ventricular ejection fraction.
  • Doppler ultrasound can also show blood flow velocities, helping to detect stenosis or regurgitation in valves.

2. Vascular and Circulatory Imaging

  • Doppler vascular ultrasound can assess veins and arteries, detecting blockages, clots (eg, deep vein thrombosis), or stenosis.
  • It’s used to examine carotid arteries (for stroke risk), peripheral arteries (leg circulation), and vascular grafts.

3. Abdominal and Pelvic Imaging

  • Ultrasound is often used to evaluate organs like the liver, gallbladder, spleen, kidneys, pancreas, and bladder.
  • It can detect gallstones, kidney stones, hydronephrosis, liver masses, or fluid collections (eg, ascites).
  • In the pelvis outside pregnancy, it helps assess uterine/ovarian pathology, fibroids, pelvic fluid, or masses.

4. Musculoskeletal (MSK) Imaging

  • Ultrasound is used to image muscles, tendons, ligaments, joints, and nerves.
  • It helps in diagnosing tendon tears, bursitis, muscle strain, nerve entrapment (eg, carpal tunnel), and joint inflammation.
  • It also guides injections or aspirations.

5. Pediatric Imaging

  • In infants and children, ultrasound is often the first-line imaging for soft tissues, head/neck, hips (developmental dysplasia), and neonatal brain (via fontanelles).
  • Because it’s radiation-free, it’s especially favorable for young patients.

6. Point-of-Care Ultrasound (POCUS)

  • In emergency, critical care, and bedside settings, physicians use handheld or portable ultrasound to rapidly evaluate ailments such as fluid around the lungs (pleural effusion), free fluid in the abdomen, cardiac tamponade, or guidance during central line placement.
  • This real-time use can expedite diagnosis and treatment.

7. Interventional / Intraoperative Ultrasound

  • Surgeons sometimes use ultrasound during procedures to locate lesions, guide resections, or assist in biopsies or ablations.
  • Interventional radiologists may use ultrasound guidance for needle placements (biopsy, drainage) and local therapies.

8. Therapeutic Ultrasound & Special Applications

  • Beyond imaging, ultrasound has therapeutic uses (eg, high-intensity focused ultrasound, ultrasound-assisted drug delivery).
  • In neurology and neuroscience, for example, therapeutic ultrasound is being explored in treating conditions like Alzheimer’s disease or other brain disorders.
  • In space medicine, ultrasound is one of the few imaging options available aboard the International Space Station (ISS). As part of the Advanced Diagnostic Ultrasound in Microgravity project, astronauts use ultrasound to assess various organ systems in microgravity.

How You Can Support Ultrasound Awareness
(Especially This October)

  • Share knowledge: If you’re a clinician or educator, talk with colleagues or patients about the many roles of ultrasound.
  • Use social media: Companies and organizations often use hashtags like #MUAM2025 to share educational images, infographics, or stories.
  • Celebrate sonographers and ultrasound technologists: Recognize the skill, dedication, and meticulous work of these professionals.
  • Invite engagement: Host a webinar, post Q&A content, or distribute simple “Did you know?” facts about ultrasound to patients.

Final Thoughts

Medical Ultrasound Awareness Month is more than a promotional event. It’s an opportunity to correct a common misconception: ultrasound is not just for pregnancy. From the heart to the knees to the kidneys, even to outer space, ultrasound plays a vital, versatile role in modern medicine.

Let’s use October’s spotlight to help people see inside, not just for babies but for better health at every age.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Logo of the American Institute of Ultrasound in Medicine (AIUM) featuring the words 'Association for Medical Ultrasound' and 'American Institute of Ultrasound in Medicine' in blue.

Echocardiography: Visualizing Our Most Vital Organ—The Heart

Posted on by
Reply

Among the constant advances in medical imaging, one innovation, ultrasound, stands out for its ability to assist us in the care of our most vital organ—the heart. Ultrasound imaging is commonly associated with monitoring pregnancies and, as a result, has become established in cardiology. This imaging modality is a noninvasive means of viewing the heart’s chambers and valves, and, in honor of Heart Health Month, I will give an overview of echocardiography and how ultrasound is a safe and effective tool in the medical care of the heart.

The Symphony of Sound Waves

Ultrasound technology relies on sound waves beyond the range of human hearing to create detailed images of the heart. Echocardiography, the specialized use of ultrasound for cardiac imaging, enables healthcare professionals to visualize the heart’s structure, function, and blood flow in real time. This noninvasive procedure has become a cornerstone in diagnosing and managing various cardiovascular conditions.

Diagnosis With Precision

One of the most remarkable aspects of ultrasound in cardiac care is its precision in diagnosing a wide array of heart conditions. From detecting congenital heart defects in newborns to assessing valve function and identifying structural abnormalities, echocardiography provides clinicians with a comprehensive view of the heart’s health.

Real-Time Insight Into Function

Unlike static imaging techniques such as X-rays or CT scans, echocardiography allows for dynamic, real-time assessment of the heart’s function. This invaluable feature aids in diagnosing conditions like heart failure, where the heart’s pumping efficiency is compromised. Clinicians can observe the heart’s ejection fraction, chamber dimensions, and wall motion, facilitating prompt and accurate treatment decisions.

Guiding Treatment Strategies

Ultrasound not only assists in diagnosis but also plays a crucial role in guiding treatment strategies. For patients with heart rhythm abnormalities, echocardiography helps identify the underlying causes, allowing for the implementation of targeted interventions such as ablation procedures. Additionally, it provides essential guidance during surgical interventions, ensuring precise and successful outcomes.

Monitoring Cardiovascular Health

Cardiac care extends beyond diagnosis and treatment; ongoing monitoring is essential for individuals with chronic cardiovascular conditions. Ultrasound enables clinicians to track changes in the heart over time, adjusting treatment plans as needed. This proactive approach enhances patient outcomes and contributes to the overall management of cardiovascular health.

Advancements in Technology

As technology continues to advance, so does the capability of ultrasound in cardiac care. 3D and 4D echocardiography now offer even more detailed and immersive views of the heart’s anatomy and function. These innovations provide clinicians with enhanced diagnostic tools, fostering a deeper understanding of cardiac physiology and pathology.

Patient-Friendly and Accessible

Beyond its diagnostic and therapeutic benefits, ultrasound in cardiac care is remarkably patient-friendly. The procedure is noninvasive, painless, and does not involve ionizing radiation, making it a safe option for individuals of all ages when performed by professionals. Moreover, the widespread availability of ultrasound machines ensures accessibility for patients across diverse healthcare settings.

Conclusion

As technology continues to evolve, so too will the capabilities of ultrasound, promising an even brighter future for the millions whose hearts need extra care.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Interested in learning more about echocardiography? Check out the following posts from the Scan:

Predicting Risk of 30-Day Readmission in Heart Failure Patients

Posted on by
Reply

Pulmonary congestion is the most frequent cause of heart failure hospitalizations and readmissions. In addition, approximately 20%–25% of heart failure patients aged 65 years and older in the United States are readmitted within 30-days after hospital discharge,1–5 despite efforts to identify predictors of readmission for acute decompensated heart failure (ADHF), such as laboratory markers, the readmission rates remain high. Lung ultrasound (LUS), however, has been shown to be a valuable tool for assessing pulmonary congestion, providing a reliable assessment based on the presence of B-lines.

A recent study by Cohen et al7 evaluated the association between lung ultrasound findings and the risk of 30-day readmission among HF patients, hypothesizing that a higher number of positive B-line lung fields on LUS will indicate an increased risk of readmission. Using a log-binomial regression model in an 8-zone LUS exam from the day of discharge, the researchers assessed the risk of 30-day readmission associated with the number of lung zones positive for B-lines, considering a zone positive when ≥3 B-lines were present. According to the results from 200 patients, the risk of 30-day readmission in patients with 2–3 positive lung zones was 1.25 times higher (95% CI: 1.08–1.45), and in patients with 4–8 positive lung zones was 1.50 times higher (95% CI: 1.23–1.82), compared with patients with 0–1 positive zones, after adjusting for discharge blood urea nitrogen, creatinine, and hemoglobin.

Ultrasound image of a lung
Ultrasound image of a lung with B-lines. The pleural line is indicated by the arrow. Emanating from the pleural line are hyperechoic reverberation artifacts, which are B-lines (indicated by the star), indicating the presence of fluid within the interstitium of the lung.

A recent study by Cohen et al7 evaluated the association between lung ultrasound findings and the risk of 30-day readmission among HF patients, hypothesizing that a higher number of positive B-line lung fields on LUS will indicate an increased risk of readmission. Using a log-binomial regression model in an 8-zone LUS exam from the day of discharge, the researchers assessed the risk of 30-day readmission associated with the number of lung zones positive for B-lines, considering a zone positive when ≥3 B-lines were present. According to the results from 200 patients, the risk of 30-day readmission in patients with 2–3 positive lung zones was 1.25 times higher (95% CI: 1.08–1.45), and in patients with 4–8 positive lung zones was 1.50 times higher (95% CI: 1.23–1.82), compared with patients with 0–1 positive zones, after adjusting for discharge blood urea nitrogen, creatinine, and hemoglobin.

This study adds to the research on LUS in patients with HF in inpatient or intensive care units and emergency departments, including studies on identifying pulmonary congestion to reduce decompensation in heart failure patients,7 the risk of hospitalization or all-cause death was greater in patients with more B-lines at discharge,8 and the prognostic value of LUS as an independent predictor of 90-day readmission.9,10

The study by Cohen et al7 expands on the prior research and demonstrates the prognostic importance of more B-lines at discharge for HF patients. Failure to relieve congestion before discharge is associated with increased morbidity and mortality and is a strong predictor of poor outcomes in patients with acute decompensated HF.

By evaluating HF patients with LUS, we may be better able to risk-stratify the severity of asymptomatic pulmonary congestion on discharge and identify patients at higher risk of readmission.

References

  1. Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation 2012; 126:501–506.
  2. Suter LG, Li SX, Grady JN, et al. National patterns of risk-standardized mortality and readmission after hospitalization for acute myocardial infarction, heart failure, and pneumonia: update on publicly reported outcomes measures based on the 2013 release. J Gen Intern Med 2014; 29:1333–1340.
  3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:e240–e327.
  4. Tavares LR, Victer H, Linhares JM, et al. Epidemiology of decompensated heart failure in the city of Niter_oi: EPICA -Niter_oi Project. Arq Bras Cardiol 2004; 82:125–128.
  5. Cleland JG, Swedberg K, Cohen-Solal A, et al. The Euro Heart Failure Survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe. The study group on diagnosis of the working group on heart failure of the European Society of Cardiology. The medicines evaluation Group Centre for Health Economics University of York. Eur J Heart Fail 2000; 2:123–132.
  6. Cohen A, Li T, Maybaum S, et al. Pulmonary congestion on lung ultrasound predicts increased risk of 30-day readmission in heart failure patients [published online ahead of print February 25, 2023]. J Ultrasound Med. doi: 10.1002/jum.16202.
  7. Araiza-Garaygordobil D, Gopar-Nieto R, Martinez-Amezcua P, et al. A randomized controlled trial of lung ultrasound-guided therapy in heart failure (CLUSTER-HF study). Am Heart J 2020; 227:31–39.
  8. Platz E, Lewis EF, Uno H, et al. Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients. Eur Heart J 2016; 37:1244–1251.
  9. Gargani L, Pang PS, Frassi F, et al. Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study. Cardiovasc Ultrasound 2015; 13:40.
  10. Coiro S, Rossignol P, Ambrosio G, et al. Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. Eur J Heart Fail 2015; 17:1172–1181.

To read more about this study, download the Journal of Ultrasound in Medicine article, “Pulmonary Congestion on Lung Ultrasound Predicts Increased Risk of 30-Day Readmission in Heart Failure Patients” by Allison Cohen, MD, et al. Members of the American Institute of Ultrasound in Medicine (AIUM) can access it for free after logging in to the AIUM. Join the AIUM today!

Interested in reading more about ultrasound? Check out these posts from the Scan:

Can We Use Ultrasound to Pace the Heart?

Posted on by
Reply

In a Heartbeat

What would it take to get back a heartbeat?

We hear about cardiovascular diseases (CVDs) all the time, with an estimated 31% of deaths globally1. It’s not uncommon to hear stories about a close friend who was young and had a heart attack. Perhaps your mom or dad had a stroke or even a neighbor who is having heart rhythm issues.

Every time I think about CVDs, the first thing that comes to my mind is my uncle. He was a healthy man in his 60s, very athletic, he used to swim and participate in marathons all the time. He never smoked, he always had a healthy diet and was active, and bam! One day, he had a stroke. To make the long story short, he ended up having to have a pacemaker implanted. He had a complication due to a pacemaker lead that was dispositioning, which caused a subsequent ischemic stroke.

Don’t take me wrong, pacemakers can be a good solution. However, complications like broken leads for instance can cause unnecessary “shocks” to the user. Complications that may occur during surgery include allergic reactions, infections, vessel damage, and heart tissue punctures.2 The weakest link in the pacemaker system, most often leading to complications, is the lead. This poses a question: Can we use an alternative source of energy to pace the heart? Can we use ultrasound as an alternative source of energy? Can we use ultrasound to treat CVDs?

If you would have a choice of another way to “control” the heart, would you do it in a heartbeat?

Cardiac Pacing

Looking back, if there was another way to pace my uncle’s heart and bring him back to a normal life, of course I would do it. Pacemakers work only when needed. If your heartbeat is too slow (bradycardia), the pacemaker sends electrical signals to your heart to correct the beat. The same principle is used if your heart is too fast (tachycardia). The pacemaker has a battery, and it works with electric energy. My goal in the last 10 years or so has been to use ultrasound as an alternative source of energy to pace the heart and to treat cardiovascular diseases.

The first step was to investigate if the ultrasound pulses can increase or decrease the heart rate (HR). Some of my preliminary studies3-5 showed that ultrasound applied to the heart of rats can cause a negative chronotropic effect (or decrease in the heart rate; Figure 1). The ultrasound protocol uses a sequence of different parameters, such as pulse duration (PD), pulse repetition frequency (PRF), etc. The PD is the distance each pulse travels and the pulse repetition frequency is the rate at which the transducer emits the pulses. The pulses must be spaced. This allows enough time between pulses, so the beam has enough time to reach the target and return to the transducer before the next pulse is generated. With a specific sequence, I was able to decrease the heart rate. Voila!

Figure 1: The top image is the baseline before ultrasound application (HR = 322 BPM), then 3 minutes after ultrasound application (HR = 230 BPM), and 15 minutes after (HR = 223 BPM).

But what if I can increase the heart rate using ultrasound pulses? In a recent investigation, I was also able to increase the heart rate with a specific sequence of ultrasound pulses (Figure 2).

Figure 2: HR at various points before, during, or after ultrasound application (points are not linearly spaced). An increase in HR was observed during each increased PRF sequence (1st, 2nd, and 3rd PRF).6

Is the Future Wireless?

We are all experiencing changes in gadgets in our daily life, from wireless vacuums to earplugs, chargers, etc. But can we pace the heart without leads? The question remains such as my uncle’s story. He’s still an active guy, but of course he needs to avoid problems like electromagnetic interference (cell phones, metal detectors, etc). Can we have a therapy that uses ultrasound to pace the heart, that is non-invasive, wireless, safe, and feasible? I hope so. Maybe one day I can change this scenario in a heartbeat!

References

1. World Health Organization. Fact Sheets: Cardiovascular Disease. Accessed: July 13, 2020. [Online]. Available: https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)

2. Pakarinen S, Oikarinen L, and Toivonen L. Short-term implantation related complications of cardiac rhythm management device therapy: A retrospective single-centre 1-year survey. Europace 2010; 12:103–108. doi: 10.1093/europace/eup361.

3. Coiado OC and O’Brien WD. The negative chronotropic effect in rat heart stimulated by ultrasonic pulses: Role of sex and age. J Ultrasound Med 2017; 36:799–808.

4. Coiado OC and O’Brien WD. The role of the duty factor in ultrasound-mediated cardiac stimulation. J Acoust Soc Am 2014; 136:EL231–EL235.

5. Coiado OC, Buiochi E, and O’Brien W. Ultrasound-induced heart rate decrease: Role of the vagus nerve. IEEE Trans Ultrason Ferroelectr Freq Control 2015; 62:329–336.

6. Coiado OC, Yerrabelli RS, Christensen AP, Wozniak M, Lucas A, O’Brien WD Jr. Positive chronotropic effect caused by transthoracic ultrasound in heart of rats. JASA Express Lett 2021; 1:08200.

Dr. Coiado, PhD, is a Teaching Associate Professor in both the Carle Illinois College of Medicine and the Bioengineering Department at the University of Illinois at Urbana-Champaign. At Carle Illinois College of Medicine, she acts as the Director of Student Research and Discovery Learning. Her research interests focus on cardiovascular studies, acoustics, bioinstrumentation, and education.

Interested in reading more about vascular ultrasound? Check out these resources:

Duplex Ultrasound in Arterial Disease in Patients With Critical Limb Ischemia

Posted on by
Reply

Critical limb ischemia (CLI) is the most severe manifestation of peripheral arterial disease (PAD) and presents with severe, chronic rest pain or ischemic skin lesions (ulcer or gangrene). It is the major cause of amputation of ischemic limbs in the United States; the annual incidence of CLI is 500 to 1000 cases per million people. Revascularization by endovascular or open surgical technique is recommended, depending on the severity of the disease.

Many imaging modalities can identify an arterial lesion that is a candidate for endovascular or open surgical technique. Angiography is the gold-standard diagnostic test but it is a high-risk, invasive, and costly procedure (Figure 1).

Figure 1. Aorto-iliac angiography showing acute ischemia involving the right common iliac artery (arrows).

Computed tomography angiography (CTA), using multidetector computed tomography (MDCT) technology and magnetic resonance angiography (MRA), is highly accurate in diagnosing PAD, equivalent to angiography. CT acquisition is rapid and less prone to motion artifacts than MRA is, but its disadvantage is exposure to doses of radiation and the use of iodinated contrast to enhance the vessel visualization. Also, CTA produces streak artifacts from heavy calcification or metallic materials, resulting in a limited evaluation of vascular patency (Figure 2).

Figure 2. CTA image of lower extremities at the onset of acute limb ischemia. The arrow indicates the short-segment occlusion of terminal aorta and bilateral common iliac arteries.

MRA produces an image without contrast or interference from calcium, but its disadvantages are it is time-consuming and expensive, it cannot be performed on patients with metallic devices or on patients who might experience claustrophobia from a closed area, and it might produce false-positive results (Figure 3).

Figure 3. MRA in a patient with pain in the left leg while walking and when resting. The arrowhead indicates stenosis in the distal part of the left common iliac artery.

Duplex ultrasound is widely available for the screening and diagnosis of vascular lesions.  It is safe without risk of radiation exposure, easily repeatable, relatively cost-effective, and causes minimal discomfort. Several studies have shown that duplex ultrasound has good sensitivity, specificity, and diagnostic agreement with angiography in assessment of lower-extremity arterial disease in critical limb ischemia. The peak systolic velocity (PSV) quantified by spectrum analysis from spectral pulsed-wave (PW) Doppler ultrasound was the most common criterion used for diagnosis and categorizing the severity of the disease in most previous studies. The duplex scanning protocol begins with B-mode and color Doppler ultrasound to identify the lesion and assess blood flow before sampling the Doppler signal by spectral PW Doppler ultrasound. The waveform feature analysis (triphasic or monophasic, acceleration time, spectral broadening, turbulence, or direction) and velocity measurement can be obtained at the proximal, distal, and overall points of the lesion when suspicion of abnormality exists. Using mutual interpretation of the findings from B-mode, color, and spectral PW Doppler ultrasound (waveform analysis and velocity measurement) is the key concept of using duplex ultrasound for the diagnosis of vascular disease and PVD (Figure 4).

Figure 4. Duplex ultrasound of the right common femoral artery (CFA). The color Doppler imaging (color box) showed totally occluded CFA in a critical limb ischemia.

Dr. Akram Asbeutah, PhD, DMU-ASUM, ASAR, ASA, FAIUM, SVU, AIR, ASRT, RT(R) ARRT, is a Clinical Associate Professor in the Department of Radiologic Sciences at the Faculty of Allied Health Sciences, Kuwait University/Adjunct, Monash University-Melbourne, Australia.

Sudden Cardiac Death in Young Athletes

Posted on by
Reply

Sudden cardiac death is very rare in young athletes (<35 years of age), however, it is the most common medical cause of death in the athletes. There are tests, commonly performed as a preparticipation screening, to detect the abnormal heart rhythms that lead to SCD, however, the tests can also have false-positive results and can miss some heart abnormalities.

There are no current standards for what needs to be included in athlete preparticipation screening but personal and family histories, physical examination (PE), and 12-lead electrocardiography (ECG) are most commonly used. Would ultrasound help to increase the efficacy of the screening?

Point-of-care ultrasound (POCUS) provides real-time bedside images that can assist in clinical decision making by potentially identifying dilated cardiomyopathy, aortic root dilatation, and coronary artery anomalies, which history, PE, or ECG frequently miss.

In a recent study to determine whether POCUS would be a beneficial adjunct to the preparticipation screening, the researchers found that although POCUS would have resulted in a 4-fold decrease in referrals, that was based on older studies using now outdated ECG guidelines. The 2017 guidelines greatly reduced the number of false-positives results, so adding POCUS as an adjunct would not create such a large decrease anymore.

POCUS did identify one primary diagnosis, left ventricular noncompaction, which was not identified by any other part of the screening. So, although the value of a POCUS adjunct may not be in reducing false-positives, it’s value may be in identifying anatomic anomalies.

Read the full article on the study by Cassels M, Moulson N, Reganin J, et al, in “Point-of-Care Ultrasound as a Component of Preparticipation Screening of Athletes: A Systematic Review” in the Journal of Ultrasound in Medicine (J Ultrasound Med 2019; 38:3123–3130. doi: 10.1002/jum.15021).

Interested in learning more about ultrasound for athletes? Check out the following resources from the American Institute of Ultrasound in Medicine (AIUM):

The Expanding Scope and Diagnostic Capabilities of Vascular Ultrasound

Posted on by
1

Peripheral Vascular Disease (PVD) in the United States affects approximately 8 million to 12 million patients a year; some experts in the field believe this number may be underestimated. The disease is associated with significant cardiovascular morbidity and mortality, with a high rate of fatal and non-fatal cardiovascular events, such as myocardial infarction, stroke, renal failure, limb amputations, abdominal aortic aneurysms, pulmonary embolus, and progressive ischemic end-organ dysfunction. The reduction in quality of life from global vasculopathy in many patients can thus be significant.

George Berdejo

George Berdejo, BA, RVT, FSVU

Prompt and accurate diagnosis of these disease processes is of utmost importance and high-quality vascular ultrasound plays an essential role. In fact, vascular ultrasound and the role of the vascular ultrasound professional has evolved and expanded rapidly and is at the core of modern vascular disease care in the United States and is emerging around the world.

Vascular ultrasound can be seen at the intersection of imaging, physiology, physiopathology, interventional medicine, and surgery and is utilized widely by healthcare providers from many specialties, including but not limited to vascular technologists and other subspecialty sonographers, vascular surgeons, vascular interventional radiologists, vascular medicine physicians, cardiologists, radiologists, and other vascular specialists with an interest in vascular disease.

At the core of any thriving vascular surgery practice is high-quality vascular ultrasound imaging. Duplex vascular ultrasound (DU) is used to evaluate all of the major vascular beds outside of the heart. The use of duplex ultrasonography for the study of vascular disease is firmly established but is also rapidly expanding. Thanks to continued improvements in the performance of ultrasound devices, vascular ultrasound can be used to perform a greater range of assessments in a noninvasive manner in some cases excluding the need for more invasive, expensive, contrast-based imaging modalities.

The recent proliferation of “less and minimally invasive” endovascular options currently available and offered to patients with various vascular disease processes has mandated better, less invasive, preferably noninvasive methods, to diagnose the disease that is being treated. Advances in technology have increased the diagnostic capabilities of vascular ultrasound and its role not only in diagnosis but also in planning and performing interventions and in patient follow-up and surveillance after intervention. Indeed, vascular ultrasound has become the standard “go-to” diagnostic imaging technique prior to most vascular interventions and has certainly emerged as the imaging technique of choice for following patients after most vascular interventions.

Endograft Evaluation. Duplex vascular ultrasound has emerged as the standard of care for surveillance after endovascular repair of abdominal aortic aneurysms. A major complication of this procedure is endoleak (persistent or recurrent flow within and pressurization of the residual aneurysm sac). This results in persistent risk of aneurysm rupture and potential death. Ultrasound assessment allows imaging and Doppler interrogation of deep structures and low-flow detection capabilities needed in patients with low-volume/low-velocity endoleak. Duplex vascular ultrasound, in good hands, has supplanted computed tomographic angiography as the primary surveillance technique in these patients. In addition, DU allows for the ability to resolve the deep structures of the abdomen to measure aneurysm sac size.

Hemodialysis Access Mapping and Surveillance. Higher frequency, better resolution, smaller footprint transducers that are currently available provide the high-resolution images that are needed to assess the veins and arteries of the upper extremity in order to plan the optimal access sites and also to provide the surveillance often needed postoperatively in order to maximize the life of the access and the quality of life for the dialysis patient.

Lower Extremity Vein Reflux Testing. Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. An estimated 40 percent of people in the United States have CVI. The seriousness of CVI, along with the complexities of treatment, increase as the disease progresses. Duplex ultrasound is integral in the evaluation, treatment and follow-up of these patients. Absent the appropriate equipment, the initial duplex reflux scan is among the most physically challenging, labor-intensive scans performed in vascular ultrasound. These exams account for 20%–25% of all the ultrasound scans performed in our practice.

Lower Extremity Arterial Mapping. Our philosophy regarding the practical evaluation of patients with known peripheral arterial disease who require intervention includes the use of duplex ultrasound as the primary first-line imaging modality precluding the use of more expensive, invasive, and nephrotoxic diagnostic arteriography in most patients.

Vascular ultrasound is now being used by increasing numbers of specialists who are employing both traditional and newer cutting-edge methods and techniques to improve patient care and management and who are dedicated to the delivery of quality care to their patients.

The future is bright for both vascular ultrasound and the vascular sonography professional!

 

Do you have any tips for performing vascular ultrasound? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

 

 

George Berdejo, BA, RVT, FSVU, is Director of Vascular Ultrasound Outpatient Services at White Plains Hospital in White Plains, New York. He is the Chair of the AVIDsymposium (www.AVIDsymposium.org) and is the current Chair of the Cardiovascular Community of the AIUM.

Novice to Competence to Understanding Our Role as POCUS Educators

Posted on by
1

Nights at the VA medical ICU could get lonely sometimes. When the hubbub of the day had drawn down and the critical care fellows had gone home, the work in the ICUs slowed.Headshot_kevin piro

I figured that I would make use of the time that had seemingly stopped. I grabbed the ultrasound and went to scan and chat with a friendly gentleman whom I had admitted the previous night. It became readily apparent that I was still a struggling learner at this point in my training. There was something that looked like cardiac motion, but not resembling anything like the diagrams and videos I had looked at on my own. It was an uncomfortable place to be.

I imagine that is where a lot of people get frustrated and stop, especially when they don’t have someone to encourage and nurture their continued practice. I had a different luxury. Just a few weeks prior, I had received an inquiry about participating in a new general medicine POCUS fellowship at Oregon Health & Science University, and I was instantly sold on its potential. Here was a chance to carve out a new path and to invest in a skill that offered me a skillset that could improve my patient care. And I knew that I would have the benefit of POCUS experts literally holding my hand as I learned the skill. What a luxury!

So, I kept scanning in the ICU prior to my fellowship. You know what I found? Patients are much more forgiving than we might imagine them to be. Most understand that hospitals are frequently places of learning and like to be engaged in the process and, as I stumbled through my next few exams, I was reminded of my Dad’s words of encouragement, “the only difference between you and an expert is that they have done it once or twice.” So I kept at it. I was terrible the next times too. But, it got easier and I felt less intimated with each scan I performed. By the time I hit fellowship, I was already moving in the right direction.

When I started my POCUS fellowship, I was fortunate to work with all sorts of supportive colleagues that allowed me to continue to grow. Where I had struggled to build a foundation on my own, colleagues collected from internists, sonographers, and EM physicians provided me with the scaffolding. They provided me with lessons. “Remember, air is the enemy of ultrasound” and “ultrasound does not give you permission to turn your brain off. It is a problem-solving tool.” They entertained clinical application questions. They gave back when I leaned in. These colleagues were an amazing support network and would help me construct the mosaic that I teach from now.

A few months into the fellowship, I could complete a competent exam comfortably. It came together one day for me when I completed a Cardiovascular Limited Ultrasound Exam (CLUE) on a pleasantly demented older man, who had shortness of breath likely representing heart failure. As I looked at his lungs, taking stock of the bilateral B-lines and pleural effusions that confirmed his diagnosis, I discussed and showed the findings with his daughter.

“This makes so much sense now!” she remarked. The lightbulb went on for her as I democratized her father’s clinical information. The lightbulb came on for me too as I had a sense of satisfaction of both feeling confident in my diagnosis, but also being better able to teach and engage a family in their medical care. My transformation from novice to competency was mostly complete.

Now, a little more than 2 years removed from my fellowship, I have a little more perspective on the road from novice to competency, not only from my personal experience but also from my opportunity to network with an amazing group of enthusiastic (IM) POCUS educators.

These educators are largely trained by their own curiosity, their attendance at POCUS CME courses, or by latching onto experts from peripheral medical departments. In essence, these educators are pulling themselves up by their own bootstraps in a time when there is a distinct scarcity of POCUS educators within Internal Medicine, which can leave the supposed “all-knowledgeable” physician in an uncomfortable place of vulnerability. They have shared the angst that POCUS is a particularly challenging skill to learn due to its humbling nature – we may not know how badly we were hearing murmurs as medical students, but I bet most learners can guess by looking at a picture how poorly they are doing when they are scanning. It was a feeling I shared back in the ICU as a resident, but our experiences diverged when I had mentors who invested in me learning this valuable skill.

But, these physicians who learned POCUS independently are now at the next, even harder, part. As new leaders, we must reach behind us and pull up the trainees, whether that be by creating the next POCUS fellowship, starting or improving a residency POCUS program, or simply training your fellow colleague. We are tasked with making new learners feel supported and encouraged, and to make this technology accessible in fields where POCUS is not the standard of care. We need to foster these learners’ growth so that they can arrive at their own lightbulb moment and so they keep scanning on the ICUs in the effort to improve the care they deliver.

 

What was your defining moment in your decision to go into ultrasound? Have you had a unique learning experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

Connect_digital_graphics_E-NEWSLETTER

 

Kevin M. Piro, MD, participated in and helped build a point-of-care ultrasound fellowship at Oregon Health & Science University (OHSU), becoming only the second general medicine-focused ultrasound fellowship in the nation. Dr Piro is now a hospitalist at OHSU.

Pioneering Ultrasound Units

Posted on by
Reply

If you think your ultrasound machine is out-dated, imagine if you still had to use these from as long ago as the 1940s. 

1940s

Ultrasonic Locator
Dr G. D. Ludwig, a pioneer in medical ultrasound, concentrated on the use of ultrasound to detect gallstones and other foreign bodies embedded in tissues. During his service at the Naval Medical Medical Research Institute in Bethesda, Maryland, Dr Ludwig developed this approach that is similar to the detection of flaws in metal. This is A-mode in its operation and was Dr Ludwig’s first ultrasonic scanning equipment.

Locator

 

1950s

Ultrasonic Cardioscope
Designed and built by the University of Colorado Experimental Unit, the Cardioscope was intended for cardiac work.

Ultrasonic Cardioscope

 

1960s

Sperry Reflectoscope Pulser / Receive Unit 10N
This is an example of the first instrument to use an electronic interval counter to make axial length measurements of the eye. Individual gates for the anterior segment, lens, and vitreous compartment provided accurate measurement at 10 and 15 MHz of the axial length of the eye. This concept was the forerunner of all optical axis measurements of the eye, which are required for calculation of the appropriate intraocular lens implant power after cataract extraction. This instrument, which includes A-mode and M-mode, was developed by Dr D. Jackson Coleman and Dr Benson Carlin at the Department of Ophthalmology, Columbia Presbyterian Medical Center.

Sperry Reflectoscope Pulser

 

Sonoray Model No. 12 Ultrasonic Animal Tester (Branson Instruments, Inc.)
This is an intensity-modulated B-mode unit designed exclusively for animal evaluations. The instrument is housed in a rugged aluminum case with a detachable cover that contains the cables and transducer during transportation. The movable transducer holder on a fixed-curve guide was a forerunner of mechanical B-scan ultrasonic equipment.

Sonoray Animal Tester

 

Smith-Kline Fetal Doptone
 In 1966, pharmaceutical manufacturer Smith Kline and French Laboratories of Philadelphia built and marketed a Doppler instrument called the Doptone, which was used to detect and monitor fetal blood flow and the heart rate. This instrument used the continuous wave Doppler prototype that was developed at the University of Washington. 

Smith Kline Fetal Doptone

 

Smith-Kline Ekoline 20
Working in collaboration with Branson Instruments of Stamford, Connecticut, Smith-Kline introduced the Ekoline 20, an A-mode and B-mode instrument for echoencephalography, in 1963. When B-mode was converted to M-mode in 1965, the Ekoline 20 became the dominant instrument for echocardiography as well as was the first instrument available for many start-up clinical diagnostic ultrasound laboratories. The A-mode was used in ophthalmology and neurology to determine brain midlines.

Ekoline 20

 

University of Colorado Experimental System
Developed by Douglas Howry and his team at the University of Colorado Medical Center, this compound immersion scanner included a large water-filled tank. The transducer moved back and forth along a 4-inch path while the carriage on which the transducer was mounted moved in a circle around the tank, producing secondary motion necessary for compound scanning. 

Compound immersion scannerCompound immersion scanner tub

 

1970s

Cromemco Z-2 Computer System (Bioengineering at the University of Washington)
This color-Doppler prototype, introduced in 1977, was the computer used for early color Doppler experiments. Z2 “microcomputers” were used for a variety of data acquisition and analysis applications, including planning combat missions for the United States Air Force and modeling braking profiles for the San Francisco Bay Area Rapid Transit (BART) system during actual operation.

Cromemco Z-2 Computer System

 

ADR-Model 2130
ADR of Tempe, Arizona, began delivering ultrasound components to major equipment manufacturers in 1973. Linear array real-time scanners, which began to be manufactured in the mid-1970s, provided greater resolution and more applications. Grayscale, with at least 10 shades of gray, allowed closely related soft tissues to be better differentiated. This 2-dimensional (2D) imaging machine was widely used in obstetrics and other internal medicine applications. It was marketed as an electronic linear array, which was faster and more repeatable without the need for a water bath as the transducer was placed right on the skin.

ADR Model 2130

 

Sonometrics Systems Inc, NY BR-400V
The first commercially available ophthalmic B-scanner, this system provided both linear and sector B-scans of the eye. The patient was examined in a water bath created around the eye by use of a sterile plastic ophthalmic drape with a central opening. Both A-scan and B-scan evaluations were possible with manual alignment of the transducer in the water bath. The instrument was developed at the Department of Ophthalmology, Columbia Presbyterian Medical Center by Dr D. Jackson Coleman, working with Frederic L. Lizzi and Louis Katz at the Riverside Research Institute.

Sonometrics Systems Inc, NY BR-400V

 

Unirad GZD Model 849
Unirad’s static B-scanner, allowing black-and-white anatomic imaging, was used with a scan arm and had similar controls as those used today, including processing, attenuation compensation, and gain.

Unirad GZD Model 849

 

1980s

American Flight Echocardiograph
This American Flight Echocardiograph (AFE) is a 43-pound off-the-shelf version of an ATL 400 medical ultrasonic imaging system, which was then modified for space shuttle compatibility by engineers at the Johnson Space Center to study the adaptations of the cardiovascular system in weightlessness. Its first journey to space was on the space shuttle Discovery in 1985 and its last on the Endeavour in 1992. The AFE generated a 2D cross-sectional image of the heart and other soft tissues and displayed it in video format at 30 frames per second. Below, Dr Fred Kremkau explains more about it.

 

To check out even more old ultrasound machines, visit the American Institute of Ultrasound in Medicine’s (AIUM’s) An Exhibit of Historical Ultrasound Equipment.

 

How old is the ultrasound machine you use now? What older ultrasound equipment have you used? Did it spark your desire to work with ultrasound? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Connect_digital_graphics_E-NEWSLETTER

The AIUM is a multi-disciplinary network of nearly 10,000 professionals who are committed to advancing the safe and effective use of ultrasound in medicine.