Program 1 - Echocardiography and Ultrasound Physics

CVT 101

Prerequisites: None

Orientation, Introduction and Human Relations

Students learn about the importance of health care delivery, medical legal aspects and medical ethics. Students learn interpersonal communications and professionalism.

Topics of discussion about discrimination, prejudice and sexual harassment will be discussed.

Students will learn about patient reception, telephone and appointments

CVT 102

Prerequisites: CVT 101

Medical Terminology

Students learn medical terminology, medical abbreviations and glossary words pertaining to cardiovascular and other medical specialities

CVT 103

Prerequisites: CVT 102

Anatomy and Physiology-- Students will learn the basic study of the human body and in detail about the Anatomy and Physiology of the Cardiovascular system.

The students will learn the following structures

The Cardiac size and location

Layers of the heart.

Basic structure components of Thoracic cavity, Respiratory system Urinary system and tissue  perfusion.

The detail structure and function of the following

Pericardium

Epicardium

Myocardium

Endocardium

The Chambers of the heart

Atrial and Ventricular chambers

Cardiac Valves

Semilunar and Atrio-ventricular valves.

Students learn in depth about the structure of the cardiac valves and the function of the valves,they also learn the development of the heart and the congential heart diseases, the lectures will cover all the congenital cardiac abnormalities so scanning information.

Cardiac Coronary Circulation

Blood flow through the coronary arteries. students learn in depth about the major coronary arteries, their branches and the segments of the heart they supply. The Anatomy of the Sinus of valsalva, the coronary arteries and in what phase of the cardiac cycle the blood flows through the coronary arteries. The blood flow through the heart and the systemic circulation. The distribution of coronory arterial supply to the myocardium is covered to teach the students that lack of blood supply will cause the segmental ischemic changes the types of infarction.

The Cardiac Venous drainage and the arterial and venous blood flow.

In and out of the heart is covered including the pulmonary circulation.

The hemodynamic changes due to volume overload of fluid in the lungs.

Transportation and Exchange of the following in the lungs & blood

Oxygen

Carbon dioxide

Waste products

Tissue perfusion and fluid exchange

Structural components and function

Constituents of blood

Pulmonary circulation

Systemic circulation

Lymphatic circulation

Embryology

Heart formation and fetal circulation

Congenital cardiac malformation

Physiology of the heart

Blood flow in & out of heart

Cardiac Valve function during diastoel and systole

Cardiac Cycle

 Relationship to the EKG

Heart sound

Cardiac valve opening and closure

Measurement site of heart rate & blood pressure

Pressures

Blood pressure

Determination of mean pressure

Pulse pressure determination

Aortic pulse pressure

Pressure in the chambers of the heart

Cardiac cycle & control mechanism

Heart rate

Stroke volume

Cardiac output

Baroreceptors & chemoreceptors

Cardiac compliance

 Preload, afterload & contractility of the heart

CVT 104

Prerequisites: CVT 101, 102 & 103

Echocardiogram findings due to the following and to synchronize with the cardiac cycle.

Conduction System

Nodes (SA&AV) bundle of Hiss & purkinje cells

Cardiac muscle fibres, gap junctions & intercalated disc

Pathways, blood supply & heart rate.

Basic Cardiovascular Electrophysiology

Trans-membrane potential

Exchange of ions

Polarization

Action potential

Depolarization

Refractory period & Repolarization

ECG Techniques & Recognition

Explain, identify, analyze & measure the following

Normal ECG traceing wave form

PQRST waves

Baseline values

Normal sinus rhythm

ECG Heart rate & PQRST

Intervals, segments, complexes

CVT 105

Prerequisites: CVT 101, 102, 103 & 104

Students are prepared to use the ECG leads and to

identify the errors before performing the Echocardiogram

ECG Leads

Bipolar, Unipolar, Precardial leads

Einthoven's triangle and law

ECG and Testing Instrumentation

ECG calibration methods

Single channel and three channel

Troubleshooting and paper speed

Recording errors

Incorrect Lead placement

Incorrect standardization

Incorrect paper speed

Recording Artefacts

Electrical interference and somatic tremor

Wandering base line etc..

Patient & Electrical safety hazards of the equipment

Broken cords, plugs and sockets

Current Leakage ground connectors

Pacemaker hazards and Electrical shock

CVT 106

Prerequisites: CVT 101, 102, 103, 104 & 105

Interpretation of abnormal ECG & abnormal Echocardiogram

Sinus arrhythmias, Sinus bradycardia, Sinus tachycardia

Atrial arrhythmias/PSVT

Ventricular arrhythmias, AV disassociation

SA blocks and sinus pause

Bundle branch block, heart blocks

First degree and second degree type 1 and type 11

Third degree block

Cardiac Pacemakers in detail explanation with

cardiac drawings showing the placements of the pacemakers.

Recognition and interpretation of normal and abnormal 12 lead ECG

Wolff-Parkinson White syndrome, explanation & ECG presentation

Myocardial infarction, injury and ischemia

Cardiac Pharmacology

Antihypertensive

Nitrates

Calcium channel Blockers

Beta Blockers

Cardiac Glycosides

Antiarrhythmic

Emergency Cardiac Medications

Epinephrine

Atropine

Verapamil

Lidocane

CVT 107

Prerequisites: 101, 102, 103, 104, 105 & 106

HEMATOLOGY

The students learn advance clinical skills pertaining to the fundamentals of the

blood components, WBC differential, platelets and RBC.

The Coagulation, thrombosis, Clot formation, the blood factors and the basic blood

chemistry and normal and abnormal blood flow pattern through the vessels.

CVT 108

Prerequisites: 101, 102, 103, 104, 105, 106, & 107

Pathology of the Heart & Blood Vessels

Abnormal Hemodynamics

The students learn the abnormal heart structure due to various causes like

congenital & due to various diseases, etiology, symptoms, pathophhisiology,

hemodynamic effect and treatment.

Congenital heart diseases

Embryology, Abnormalities of the Atria and the ventricles

Abnormal blood flow and right & left outflow tract obstruction

Intra-cardiac shunts, ASD, VSD & PDA

Cardiac Valves abnormalities

Surgical procedures

Cardiac Valves diseases

The students learn in detail about the diseases which affect the valves

Mitral valve disease, Aortic valve disease, Tricuspid valve disease and Pulmonary valve disease.

Valve repair, valve replacement

Types of artificial valves used for different cardiac valves

Ischemic cardiac diseases

Coronary Artery disease, Atherosclerosis, Spasm of the arteries and due

to other colagen diseases.

Myocardial infarction, complications of MI, rupture of papillary muscle, septum,

wall, aneurysm resulting in cardiac tamponade etc.

Cardiac wall motion abnomalities, a detail explanation with the drawing of

cardia wall segments, Types of wall motion abnormalities.

Associated problems, thrombi, obsturction, Arrhythmia & conduction disturbance.

Inflammatory Heart Disease

Diseases affecting the layers of the heart

Endocarditis, Myocarditis & Pericaiditis

Cardiomyopathy

Dilated, Constrictive, Restrictive

Hypertrophic, Obstructive and non-obstructive Cardiomypathy

Cardiac Masses

Benign and Malignant

Hypertension, Systemic and pulmonary hypertension.

A detail explanation of the hemodynamic changes including the tissue perfusion arterioles,

venules and the lymphatic, detail explanation of role of the lymphatics

components and circulation of the lymphatic fluid back to the heart.

Pericardial Diseases

Pericarditis, pericardial effusion, grading of the effusion.

Constrictive pericarditis, calcified, tuberculosis, the pericardial,

hemodynamic changes & compensatory mechanisms.

Interventional procedures

CABAG, valvular replacement

Catheterization, pacemaker placement and

Cardiac Transplants.

Diseases of the Aorta

Congenital and Acquired

Aneurysm of the Aorta

PDA and Coarctation fo the Aorta.

Paediatric Pathology, cardiac malformation

and abnormal hemodynamics

CVT 109

Prerequisites: 101, 102, 103, 104, 105, 106, 107 & 108

EVALUATION OF CARDIOVASCULAR SYSTEM BY ULTRASOUND

Pericardium

Students learn scanning to clinical evaluation of pericardium,

for pericarditis, chronic pericarditis, calcification, to identify the signature effect,

pericardial effusion, measurements and grading of the pericardial effusion.

Constrictive pericarditis, hemodynamic changes, increased venous pressure etc.

Cardiac tomponade, evaluation of Aortic root or rupture of the myocardium.

Myocardium

Evaluation of myocardium by ultrasound scanning to detect myocardial infarction,

to identify the location of MI & segmental abnormality, type of the scar

wall motion abnormality, to identify the type of wall notion abnormality,

aneurysm (true or pseudo aneurysm)

Myocardium wall thickness, papillary muscle, cardiomyopathy & tumours

Cardiac Chambers

Atria and ventricles

Size normal or abnormal, measurement, clot, near the apex of floating blocking the blood flow through

the Mitral valve, Myxoma with the stalk or without the stalk.

Congenital heart diseases

Abnormalities of the Atria & systemic vein drainage.

Anomalies of the ventricles & outflow tract obstruction, abnormalities of the great

vessels and intracardiac shunts ASD & VSD

Cardiac valves

Evaluation of Cardiac valves by ultrasound for the following

Mitral or Tricuspid valve Prolaps

Cardiac valves

Valves closing properly or incompetant, blood flow through the valves normal or

regurgitation, evaluate by colour doppler, BART.

Grading of the regurgiation, mild moderate & severe or percentage calculation.

Students learn to calculate the percentage calculation of regurgitation.

To identify the valve structure abnormality due to diseases & congenital

Ebstein Anomaly, Bicuspid Aortic valve other cardiac anomalies in detail

Hemodynamics

Colour doppler to evaluate the blood flow in and out of the heart through the

cardia valves, to identify the regurgitation, volume abnormalities in the cardiac chambers & EF

PA pressure, Echo calculations of the Cardiac functions in normal & abnormal

Cardiac evaluation by Echocardiogram is covered in detail in CVT 111

CVT 110

Prerequisites: 101, 102, 103, 104, 105, 106, 107, 108 & 109

Ultrasound Physics & Instrumentation

History of ultrasound application in Medical field

Sound beam formation

Near field, Far field and Focal Zone

Beam focusing

Physical properties of ultrasound

Properties, definition and the explanation of the following terms used

Cycle, Wavelength, Velocity, Frequency and the Harmonics.

Velocity of sound in human tissue

Propagation speed in different media, Air, Tissue & blood

Acoustal properties of tissue

Detail lecture, the drawings used to help the students to understand the following

Impedance

Reflection

Refraction

Absorption

Impedance & interfaces

Specular Echoes Scattered Echoes

Resolution and Attenuation

Transducers

Design

Types of transducers

Focused single crystal, Annular Array

Phased Array transducers and Mechanical transducers

Piezoelectric effect

Beam focusing

Near field & Far field

Lateral Resolution and Axial Resolution

Axial Resolution

Elements

Beam Steering

Definitions and detail explanation of the following

Frequency, Wave length,

A-mode

B-mode

M-mode

Bandwidth

Hertz

Power

Range and velocity

Laws: Ohm's law, Poieseuille's law, Bernoulli's

Doppler Instrumentation

Pulsed Wave

Continuous Wave

Signal processing, the following are covered in detail

Integral time analysis

Decibel gain

Digital signal

Dynamic range

Fast Fourier transformation

Post scan processing

Scan converters

Zero crossing detector

Time gain compensation, TGC graph and reason to use in patients

Principles of Doppler

Doppler effect

Doppler equation

Doppler Instrumentation

Continuous Wave

Advantages of continuous wave is detection of high velocity

Disadvantages is range definition

Pulsed Doppler

Limitations, Aliasing Nyquist effect, effect on flow and velocity, PRF

High pulsed repetition frequency pulsed Doppler, effect on Nyquist effect

Doppler Display

Doppler Control

2-D Doppler and color flow

Color flow mapping, sampling methods, Artifacts and limitations

Processing, display and Instrumentation

Imaging, Doppler and color flow artifacts

Computer manipulation of data, storage, displays and recording devices

Quality control, troubleshooting and preventive maintenance

Biologic Effects and Safety mechanism & bio-effects

Electrical and mechanical hazards

Quality Improvement

Instrumentation precautions

Preventive maintenance

General concepts

Mathematics

Fractions

Percentage

Ratios

Exponents & exponential notations

Units of measurements

Length-distance

Mass-weight

Area and volume

Time

Temperature

Statistical Analysis

Descriptive statistic

Mean, Median, Range, mode

Inferential statistics

Standard error of mean

Standard deviation

Analysis of variance, sensitity and specificity

CVT 111

Prerequisites: CVT 101, 102, 103, 104, 105, 106, 107, 108, 109, 110

Normal and Abnormal functions of the Heart evaluation by Echocardiogram

M-Mode

Colour Doppler and Color Flow

Cardiac Calculations by Echo

Basic and advance techniques and imaging planes

Normal values, quantitative measurements and calculations

Qualitative evaluation of cardiac chamber and myocardial wall segments

Hemodynamic information derived from Echocardiograms

Normal Parameters

Measurements and Equations, detail explanation with drawings and hand outs

2-D imaging, recognition and assessment of the following

Pericardial disease, pericardial effusion grading

Cardiomyopathy

Congenital heart disease

Cardiac masses

Valvular heart disease

Inflammatory heart disease

Ischemic heart disease

Myocardial infarction and wall motion abnormality

Left ventricular function, FS and ejection fraction

Systemic and Pulmonary hypertension

Prosthetic valves.

Cardiac Doppler and Color Echocardiogram

Normal and abnormal blood flow patterns

Normal values, quantitative measurements and calculations

Advanced Techniques in Echocardiogram

Trans-esophageal Echocardiogram TEE

Ultrasound Contrast study

Stress Echocardiogram

Indication and contraindication

Protocols, Bruce and modified Bruce

Tread mill stress test

Pharmacologic stress testing using the following

Dipyridamole

Dobutamine

Thallium

Cardiolyte

CVT 112

Prerequisites: 101, 102, 103, 104, 105, 106, 107, 108, 109, 110 & 111

ECHO Findings in abnormality of the vascular system & how it can affect the Cardiac function

Blood Flow Patterns

Normal and abnormal Arterial blood flow

Laminar, parabolic and plug flow pattern

Disturbed and Turbulent blood flow pattern

Structure of arteries & veins

Location, physiology & pathology of the following

Carotids

Aorta

Ascending Aorta

Descending Aorta

Abdominal branches

Lower and upper extremity arteries

Venous

Abdominal venous system

Lower extremity veins, deep, superficial and perforators

Upper extremity veins, deep and superficial

Normal & abnormal blood flow

Patients assessment and obtaining patient history

Hypertension

Cold sensitivity

Chronic or acute Arterialocclusive disease

Stroke

Obesity

Previous DVT

Trauma, smoking bed rest patients & age

Diabetes

Hyperlipidaemia

Transient ischemic attacks TIA

Previous surgery

Chronic, acute venous insufficiency and acute vein thrombosis

Medications, birth control pills

Cardiac surgery and cardiac problems

Vascular surgery

Carotid endarectomy

operative survey and Postoperative survey

Bypass Grafts

Percutaneous Intervention

Angioplasty and stent

Pathology

Atherosclerosis

Atherosclerotic plaque

Arteritis

Stenosis

Hematomas

Embolism

Aneurysm

Entrapment syndromes

Arteriovenous fistulas

Thoracic outlet syndrome

Raynauds disease, syndrome

Kawasaki disease

CVT 113

Prerequisites: 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112

Medical Ethics & Confidentiality of Patients Reports and Ultrasound Facility

Ultrasound Department and Technical Support

Scanning room, Medical records

Patients care

Legal and professional responsibility

Patient identifiation

Verification of requested examination

Legal and Medical ethics

Patient Education, Safety and comfort

Communication with patients

Assessment of patient's condition

Proper body mechanics for patient transfer

Patient Privacy

Basic Patient Care

Standard Regulation and Techniques

JCAHO standards

Universal precautions/ OSHA regulations

Prevention of Infection and control

Isolation Techniques.

CVT 114

Prerequisites: 101,102,103,104,105,106,107,108,109,110,111,112,113,114

ECHOCARDIOGRAMS

Scanning Protocols, detail explanation with drawings and Tape demonstration

Vascular & Echo cardiogram, segmentl approach of Cardiac Anatomy

Basic and Advanced techniques and imaging planes

Normal Values and quantitative measurements and calculations.

ECHOCARDIOGRAPHIC PROTOCOL

PlAx

2D parasternal long axis view 4-6 beats

Open LV, visualize endocardium

Visualize AO and MV

Zoom on Mitral or Aortic valve if deformity is noted

Without color do the measurements of LVOT and LA

M•Mode measurements of Aortic root, valve and LA.

The measurements of LV in diastole and systole to get EF.

EF can be obtained by simpsons & modified sympsons method ,

it is more accurate but face little difficult to trace

the inner wall of the LV. Follow your work place lab protocol.

LV at the maximum volume (MV open)

Measure

RVDd

IVSd

LVDd

LVPWd

Measurements in systole (AV open, LV at the minimum volume)

LVDs

LVOT, just before the cups

AO root, after the AV cusps, across the AO.

LA, parallel to MV when closed.

MV measurements, move cursor at the tip of the MV

Freeze measure

D-E excursion

E-F slope
EPSS (septal separation)

2D- From PLAX, rotate counterclockwise and angle down

towards right hip. Rock probe to bring RVIT towards the center of the sector.

If blue jet is present, this represents TR Doppler,

place the cursor through RV,RA, sample gate above TV.

Freeze and get E point and A point to get the maximum velocity.

Trace profile to get pressure gradient.

If regurge is present on color, Doppler with CW obtain an envelope

Freeze and measure peak velocity and add 10 mmHg for RSVP & PA.

If Mitral regurgitation is present trace and quantify the

Mitral jet area to LA area. Calculate the percentage. The severity of the regurgitation

is depending upon the percentage.

Apical 5 chamber View, 2-4 beats

Add colour to discrete sector from Aortic Sinus into LV,

including AV, 2-4 beats

If Aortic regurgitation is present proceed to quantify as mentioned earlier.

Apical 2 chamber View, 2-4 beats.

Only necessary if Mitral regurgitation present.

Colour across MV and demonstrate the regurgitation jet in the left atrium.

Apical long Axis View, 2-4 beats

Add colour if Aortic Regurgitation is present proceed as

above to map with colour flow Include a color flow

sector showing the Aortic root, Aortic valve, basilar portion of LV

and the left Atrium

Apical 4 chamber with color flow across

the Tricuspid Valve. 4-6 beats

If TR noted perform spectral continuous wave Doppler

to identify the peak tricuspid regurgitation velocity.

When ever a TR Velocity exceeds 2.5 meters/second,

obtain parasternal short axis of pulmonic valve with color

and subcostal view demonstrating IVC size and respiratory

motion characteristics.

If patient has Aortic Regurgitation, obtain parasternal axis view

of Aortic valve and add color flow at level of leaflet.

Determine the Aortic regurgitant jet area to Aortic root diameter,

get the ratio of height of the jet to the Aortic root diameter, also

perform M- mode measurement of Aortic root and also M-Mode

measurement of left ventricle.

If patient has Aortic Regurgitation, perform pulsed Wave and

Continuous Wave spectral analysis of Aortic Regurgitant jet from

the apical 5 chamber and apical long axis Views.

Quantify the peak Aortic regurgitant velocity and regurgitant slope.

If patient has Mitral Regurgitation

Perform CW of Mival regurgitant jet. Also obtain

M- Mode rneasurernent of Left Atrium and Left Ventricle

RVOT

2D- From PLAX, angle up towards the left shoulder and show

RVOT with the PV.

Colour box on PV (blue)

Sample gate above PV on the RV side

PW and spectral, obtain the spectral profile envelope below the

baseline Trace the envelope to get the pressure gradient.

If pulmonary regurge is present (red flame). sample gate above PV

use CW and spectral (positive profile)

Freeze measure deceleration slope (P1/2 t) of the PR

If Aortic regurgitation (red flame like back into the LVOT) is

noted, continue with detail study of the valve and the regurgitation ,

pay attention to characterize the jet i.e. mild, moderate or severe by

width, length, turbulence,depth of regurgitation into the left ventricle.

Freeze frame and quantify the Aortic regurgitant

jet height to Aortic root

Zoom with colour and observe if lesion is noted.

PSLX add color to sector showing Mitral valve and Left atrium, 4- 6 beats.

If MR is present, it will present as a blue jet back into the L.A.

If Mitral Regurgitation is noted, continue with detail study

of Mitral regurgitation in relation to left atrium,

quantify the Mitral regurgitant jet area to left Atrial area,

it can be done in the apical view also.

If there is abnormality is noted, zoom with colour flow and observe.

Apical four chamber view, 4-6 beats

Open ventricles and atrium, center IVS visualize MV and TV.

Place color box over MV (red) ) if blue jet is seen in LA, regurg is present.

With CW Doppler to measure regurgitant peak velocity.

Doppler, with sample gate above MV at the tip of the leaflets, (open)

PW and spectral (positive profile)

Freeze and measure

E point and A point

Pl /2t or deceleration slope.

Go back to TV with sample gate above the valve. PW & spectral

Freeze and measure E point and A point.

Observe the chambers, cardiac valves and any abnormality in the cardiac chambers .

Then add color to see the flow of blood through the valves.