Course Syllabus

Introduction

  1. Indications, contraindications, standard views, knobology
    • ASE TOE indications and contraindications
    • Complications
    • Probe insertion and manipulation
  2. Safety
    • Clinical Dosimetry
    • Biological Effects of Ultrasound
    • Electrical and Mechanical Safety
    • Infection Control
  3. Comprehensive exam – complete exam and normal anatomy in each view
  4. Reporting

Left Ventricle

  1. Left Ventricular systolic function
    • LV TOE views and anatomy
    • LV chamber size
    • LV mass
    • Global LV function
      • FS – 2D/M mode
      • Velocity of circ shortening
      • FAC
      • EF – Simpsons
      • EF – 3D
      • Other – dP/dT, MAPSE, S’ TDI velocity, MPI/Tei index
      • SV – LVOT area x VTI
  2. Regional LV function
      • 17 segment model
      • Coronary artery perfusion
      • RWMAs grading
  3. LV aneurysm/pseudoaneurysm
  4. LV rupture

Right Ventricle

  • RV anatomy/geometry
  • RV TOE views and anatomy
  • RV chamber size and EF
  • RV function
    • RV FAC TAPSE
    • Other – Eccentricity index, RV dP/dt, S’ TDI velocity, IVA, RV MPI/Tei index
    • RVEF 3D TOE

Aortic Stenosis

  • AV anatomy
  • AV TOE views and anatomy
  • Aetiology of AS
  • Indications for surgery
  • Aortic sclerosis
  • Pathophysiology + LVH

Quantification

  • Mean/Peak gradient,
  • AVA – 2D plannimetry, 3D planimetry, Continuity equation
  • Double envelope – Dimensionless index

Low gradient AS

TAVI – TOE for TAVI

Physics I and II

Basic principles

  • Nature of Ultrasound: Compression and Rarefaction
  • Frequency, Wavelength, Tissue Propagation Velocity
  • Properties of Ultrasound Waves
  • Ultrasound/Tissue Interactions

Transducers

  • Piezoelectric Effect
  • Crystal Thickening and Resonance
  • Damping
  • Sound Beam Formation
  • Focusing
  • Axial and Lateral Resolution
  • Arrays

Imaging

  • Instrumentation
  • Displays
  • Imaging Modalities
  • Signal Processing and Related Factors

Principles of Doppler Ultrasound

  • Doppler Effect
  • Doppler Equation
  • Doppler Shift Frequencies and Influencing Factors
  • Nyquist Limit
  • Spectral Analysis and Display Characteristics
  • Pulsed-Wave Doppler
  • Continuous-Wave Doppler
  • Colour Flow Doppler
  • Colour M Mode

Aortic Regurgitation

  • AV anatomy
  • AV TOE views anatomy and dimensions
  • Mechanism AR
  • Pathophysiology + LV dilation
  • Indications for surgery
    • Quantification
    • VC/PHT/jet width:LVOT/CW jet density
    • EROA (PISA)/Regurg fraction
    • Reversal flow desc aorta

Mitral Regurgitation

  • MV anatomy and nomenclature
  • MV TOE views + anatomy
  • Mechanism
  • Quantification
    • CFD jet area/CW density/Pulm vein flow
    • VC/Mitral inflow VTI
    • EROA/PISA/Regurg volume/Regurg fraction
  • 3D imaging
  • Post surgery – incl LCx injury/AV disruption
  • SAM
  • Percutaneous interventions for mitral valve and LAA

Mitral Stenosis

  • MV anatomy and nomenclature
  • MV TOE views + anatomy
  • Aetiology
  • Pathophysiology
  • Indications for surgery – incl surgery vs valvotomy
  •  Quantification
    • MVA – 2D planimetry/3D planimetry/PHT/Continuity equation
    • Mean gradient
    • EOA/PISA

Thoracic Aorta

  • Aortic anatomy
  • Aortic TOE views and dimensions
  • Limitations to TOE for thoracic aorta
  • Aortic dissection classification
  • TOE assessment dissection
  • Flap
  • True vs false lumen
  • Entry tear
  • Thrombus
  • Other – AR/coronary involvement/pericardial/pleural effusion
  • Surgery for dissection
    • TAA classification
    • Aetiology TAA
    • Indication for surgery
  • Traumatic injury
  • Atherosclerosis

Congenital Heart Disease I

  • Identification of Morphologic Left and Right Structures
  • Assessment Post Surgical Repair
  • Pulmonic Valve and Right Ventricular Outflow Tract Abnormalities
  • Aortic Valve and Left Ventricular Outflow Tract Abnormalities
  • Coronary Artery Anomalies
  • Patent Ductus Arteriosus
  • Coarctation of the Aorta
  • Ebstein’s Anomaly
  • Persistent Left Superior Vena Cava
  • Tetralogy of Fallot
  • Transposition of the Great Arteries
  • Single Ventricular Procedures
  • Truncus Arteriosus
  • Cor Triatriatum

Diastology

  • Cardiac cycle
  • Phases of diastole
  • Physiology of diastole
  • Indices of relaxation
    • IVRT
    • Peak negative dP/dT
    • Time constant of relaxation
  • Echocardiographic Assessment of Left Ventricular Diastolic Function
    • Heart morphology
    • Transmitral inflow
    • TDI annular velocities
    • Others – Pulmonary vein flow/DT/Propagation velocity/E-e’ time interval/TR peak velocity
  • Grading of Left Ventricular Diastolic Function
  • Estimates of Left Ventricular Diastolic Filling Pressures
  • Special population assessment  – e.g. AF/ST/MS/MR/ etc
  • Right Ventricular Diastolic Function

Pericardial Disease

  • Pericardium and pericardial space/sinus anatomy
  • Acute Pericarditis
  • Normal variation in right and left heart transvalvular velocities, chamber filling and septal movement during respiration
  • Constrictive Pericarditis
    • Aetiology
    • TOE findings
    • Doppler measurements
    • Respiratory changes
    • CP vs RCM
  • Pericardial effusion
    • Aetiology
    • TOE assessment
    • Tamponade physiology
    • Chamber sizes and collapse
    • Doppler measurements
    • Respiratory changes
    • Tamponade vs Constrictive pericarditis
  • Other pericardial disease – masses/cysts/diverticulum/congenital absence
  • Pleural spaces – TOE assessment and anatomy

Cardiac Tumours and Masses

  • Normal structures/variants
  • Thrombus
  • Vegetations
  • Indications for surgery I.E.
  • Tumours
    • Primary Malignant
    • Primary Benign
    • Secondary
  • Other non-malignant – e.g. lipomatous hypertrophy/llambls etc
  • Devices and Foreign Material

Congenital Heart Disease II

  • Atrial Septal Defects
    • Embryology
    • Classification – PFO/Primum/Secundum/Sinus Venosus/Coronary Sinus
    • Incidence
    • Associated lesions
    • Pathophysiology/Eisenmengers
    • Shunt equation
    • TOE assessment and views for each type
    • Percutaneous interventions
  • Ventricular Septal Defects
    • Classification – type 1-4 (alternative nomenclature)
    • TOE assessment and views for each type

Tricuspid and Pulmonary Valves

  • TV anatomy
    • TV TOE views and anatomy
    • TR aetiology
    • Indications for surgery
    • Quantification TR
    • TS Aetiology
    • Quantification TS
  • PV anatomy
    • PV TOE views and anatomy
    • PR aetiology
    • Quantification PR
    • PS Aetiology
    • Quantification PS
  • Carcinoid disease
  • Percutaneous interventions for the tricuspid valve

Cardiomyopathies

  • Classification
  • HCM/HOCM
    • LVH/LV mass
    • Aetiologies
    • Progression
    • TOE features of HOCM – LVOT velocity profile//M mode AV valve
    • Myectomy measurements
    • Post myectomy – VSD vs perforators
  • DCM
    • Aetiology
    • Chamber measurements
    • Apical Thrombus
  • RCM
    • Aetiology
    • Restrictive vs constrictive
    • ARVC
  • Atypical
    • Takotsubo
    • Non-compaction
    • Atavism

Epicardial & Epiaortic scanning, Coronary anatomy, IABP

  • Epicardial
    • Imaging Views
    • Anatomy
  • Epiaortic
    • Indications
    • Imaging planes and anatomy
  • Atherosclerosis
  • Revision of aortic pathology
  • IABP
    • Position
    • Contraindications
  • Coronary Arteries
    • Anatomical position of coronary ostia
    • Flow patterns
    • Reimplantation buttons

Prosthetic valve assessment, VADs, Impella devices

  • Types of prosthetic valves
    • Mechanical – bileaflet/single tilting disc/caged ball
    • Bioprosthetic – stented/stentless/percutaneous
  • 2D/3D assessment
  • Doppler evaluation
  • Regurgitation – physiological vs pathological vs paravalvular
  • Early and late complications
  • VADs
    • Indications
    • Types
    • Pre-assessment TOE – LV/RV/Intracardiac Shunts/AR/TR/Thrombus etc
    • Device placement – Cannula position/doppler etc
    • Function and complications
    • Low flow/High flow/Unloading
    • Calculation of flow through VAD – AV open/closed and AR present/absent
  • Percutaneous VADs
    • Impella
    • Tandem heart

3D TOE, Strain, Artifacts, pitfalls, extras

  • 3D
    • Acquisition/modes –live/full volume/3D zoom
    • Challenges – temporal vs spatial resolution/stitch artefact/cropping
    • LV EF
    • MV
    • Other – valves/ASD/LAA etc
    • Measurements – 3D LVOT area/VC etc
  • Strain
    • Definition
    • Longitudinal/Circumferential/Radial
    • Global vs Regional
    • Strain rate
    • TDI vs Speckle tracking
  • Artifacts
    • Reverberations
    • Side lobes
    • Shadowing
    • Near field clutter
    • Refraction
    • Aliasing
    • Ghosting
    • Mirror images
    • Range ambiguity
  • Pitfalls
    • Anatomical variants e.g. Eustachian valve/Chiari network/Christa Terminalis/Coronary sinus/L SVC/Thebesian valve/Moderator band/Pectinate etc
    • Measurement pitfalls e.g. CFD nyquist/Doppler angles etc

Haemodynamic calculation revision

Revision of calculations including:

  • Doppler
  • Bernoulli/intracardiac pressures
  • Pressure half-time
  • Continuity equation
  • PISA
  • Regurgitant volume / fraction
  • Shunt

Topic revision, Q&A

Mock Exam