The Standard Echocardiographic Exam in Small Animals

THE STANDARD ECHOCARDIOGRAPHIC EXAM IN SMALL ANIMALS
D. Piantedosi*, P. Ciaramella
Department of Veterinary Medicine and Animal Productions, University of Naples Federico II, Via
F. Delpino 1, 80137 – Naples, *E-mail: [email protected]
The echocardiographic examination usually starts with the two-dimensional technique

(B-mode), also called real time echocardiography. The two-dimensional technique allows the
evaluation of anatomy and spatial relationship of cardiac structures. Monodimensional (M-mode)
and Doppler echocardiography represent other imaging modalities overlapped and guided by
two-dimensional imaging. For the echocardiographic exam it is necessary use specific
transducers, called “phased-array”. These probes work with a high frame rate, are adapted to the
application in the intercostal space, and allows simultaneous B-mode and Doppler acquisition
(duplex or triplex imaging) (1).
Dogs and cat usually require little preparation for echocardiography. The cutting of the
hair is crucial for obtaining proper diagnostic images. Usually sedation is not required for its
undesirable effects on chamber dimensions, left ventricular motion and blood flow velocities,
and it must be used only in very uncooperative animals. Regarding the position of the patient
during the exam, the image quality is enhanced by positioning the animal in lateral recubency on
a table with a hole that allows transducer manipulation from beneath the patient.
The standard transducer locations on the thorax, called “windows”, are three and allow
the view for standard imaging planes for two-dimensional echocardiography: 1) Right
parasternal location: 3rd-6th intercostal spaces (IS) (usually 4th-5th) between the sternum and
costochondral junctions; 2) Left caudal (apical) parasternal location: 5th-7th IS as close to the
sternum as possible; 3) Left cranial parasternal location: 3rd-4th IS between the sternum and
costochondral junctions. Subcostal location is an ancillary window that allows a perfect
alignment of the ultrasound beam with the aortic blood flow (2). Imaging planes obtained from
each transducer location are indicated as “views” and are named with respect to their orientation
with the left ventricle or ascending aorta. A “long-axis plane” is a plane that is longitudinal to the
long axis of the heart from apex to base. A “short-axis plane” is a plane that is perpendicular to
the long-axis of the heart. Each view is further identified by the number of cardiac chambers
imaged. The B-mode is used to assess the cardiac structure, shape and thickness of the
myocardial walls, chamber dimensions and valvular aspect. Also, this mode serves as a ”basic-
view” for M-mode and Doppler mode. Furthermore, linear, areal and volumetric measurements
can be performed, providing the possibility to calculate distances and areas. The most common
measurements in B-mode are linear measurements for the left and right ventricle in both systole
and diastole, left atrium to aorta ratio and area-length measurement for calculating the left
ventricle ejection fraction.
A B
C D
Fig. 1. Cardiac ultrasonography of a dog in B-mode A. Right parasternal long axis, 4 chamber view, showing the left
ventricle (VS) and the left atrium (AS); B. Right parasternal short axis view showing the left ventricle with the papilary
muscles; C. Right parasternal short axis view through the heart base, showing the aorta (Ao), left atrium (AS) and the
right ventricle dorsally; D. Left parasternal long axis, 4 chambers apical view, visualising the left and right ventricles
(VS, VD) and the left and right arium (AS, AD);
B-mode may evince myocardial and endocardic structural changes such as fibrosis seen
as hyperechoic areas within the myocardium or on the valvular aspect, or cardiac tumors.
Pericardial changes may also be diagnosed with B-mode. Pericardial fibrosis is observed as a
hyperechoic and thickened line surrounding the myocardium. Fluid accumulation inside the
pericardium is revealed by an anechoic band between the myocardium and the pericardium (3,
4).
M-mode ehocardiography uses a narrow ultrasound beam to image only a small portion
of the heart and detect only the axial motion of cardiac structures. M-mode technique is guided
by B-mode and individual cardiac structures are imaged by moving a single ultrasound beam
from apex to base of the heart. The M-mode does not reproduce the heart anatomy and cardiac
structures are identified by their characteristic motion pattern. Depth is represented on the
vertical axis and time is represented on the horizontal axis. A simultaneous ECG is used as time
reference of the cardiac cycle. M-mode exam is very important for accurate quantification of
cardiac chamber sizes, wall thicknesses, wall motion and valve motions. Furthermore, it allows
the calculation of the ejection phase indices of cardiac function, such as Shortening Fraction (FS)
and Ejection Fraction (EF) (5).
A B
C D
Fig. 1. Cardiac ultrasonography of a dog A. M-mode of the left ventricle with a section between the papilary muscles:
measurements of the ventricular walls and cavity allow the calculation of the shortening and ejection fraction using the
Teicholz formula. B. Pulse-wave Doppler assessing the aortic flow velocity from the left parasternal long axis, 5
chamber apical view C. Pulse-wave Doppler assessing the pulmonary flow velocity from the right parasternal short axis
view through the base of the heart D. Pulse-wave Doppler assessing the transmitral flow through the left parasternal
long axis, 4 chambers apical view; the transmitral flow pattern is considered a strong predictor for the left ventricle
diastolic disfunction;
Doppler echocardiography is based on Doppler Equation enunciated by Christian Johan

Doppler in 1842. It uses the change in frequency of an ultrasound beam that occurs when it
reflects from moving blood cellular elements. It allows the study of the cardiac blood flows and
defines flow velocity, direction and quality (laminar or turbulent flow). Doppler imaging is
particularly valuable in the diagnosis of acquired valvular heart diseases and congenital heart
diseases, in which abnormal flow jets are present. Doppler echocardiography includes three
different modalities: 1) pulsed-wave (PW); 2) continuous-wave (CW); 3) color-flow mapping
(CFM). PW and CW are reported as “spectral doppler” and the recordings are displayed with
velocity on vertical axis and time on horizontal axis. As for M-mode recording a simultaneous
ECG is recorded to synchronize the flow signal to cardiac cycle. PW Doppler allows the
selection of a distinct area of interest where the flow signal is sampled, but has limitations in
measuring the maximum detectable velocity for its dependence on pulse-repetition frequency
(PRF) called the “Nyquist limit”. CW Doppler eliminates the problems due to PRF transmitting
and receiving continuously, thus making it possible to measure very high velocities accurately
(6).
PW Spectral Doppler tracing of the trans-mitral flow is represented as two waves above
the baseline: 1) the early-diastolic E wave (that is due to passive ventricular filling) and late-
diastolic A wave (that is due to atrial contraction). PW Spectral Doppler tracings of the right and
left outflow tracts are represented as a single laminar wave direct away from the transducer.
CFM uses PW technique to build color-coded images of blood velocity superimposed over the
two-dimensional anatomic images of the heart. Conventionally the laminar flow toward the
transducer is coded red, while laminar flow away from the transducer is coded blue. High-
velocity turbolent flow, associated to a valvular regurgitant jet and congenital cardiac shunts, is
represented as a mosaic pattern consisting of a mixture of multiple colors. CFM offers some
advantages than Spectral Doppler, because covering a much greater area of sampling and
regurgitant jets and shunts are more rapidly recognized (7).
1. Henry WL, DeMaria A, Gramiak R, King DL, Kisslo JA, Popp RL, et al. Report of the American
Society of Echocardiography Committee on Nomenclature and Standards in Two-dimensional
Echocardiography. Circulation. 1980;62(2):212-7. Epub 1980/08/01.
2. Boon JA. Veterinary echocardiography. 2 ed: Wiley Blackwell; 2011.
3. Fox PR, Sisson D, Moise NS. Echocardiography and doppler imaging. Textbook of canine and
feline cardiology. Philadelphia: Saunders; 1999. p. 107-30.
4. Chetboul PV, Pouchelon JL, Tessier D, Bureau S, Blot S, Cotard JP, et al. Echographie et doppler
du chien et du chat, Atlas en couleur: Ed. Masson; 2005.
5. Schober KE, Baade H. Comparability of left ventricular M-mode echocardiography in dogs
performed in long-axis and short-axis. Veterinary radiology & ultrasound : the official journal of the
American College of Veterinary Radiology and the International Veterinary Radiology Association.
2000;41(6):543-9. Epub 2000/12/29.
6. Chetboul PV. Echographie et Doppler du Chien et du Chat. Paris: Masson; 2005.
7. Smith FWK, Oyama M, Tilley L, Sleeper M. Manual of Canine and Feline Cardiology. 5 ed. St
Louis, Missouri: Elsevier; 2016.

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THE STANDARD ECHOCARDIOGRAPHIC EXAM IN SMALL ANIMALS

The echocardiographic examination usually starts with the two-dimensional technique

Doppler echocardiography is based on Doppler Equation enunciated by Christian Johan

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