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COMPANION ANIMAL PRACTICE Colour Doppler image of a

ventricular septal defect in a

cat, showing red-coded flow
from the left ventricle into
the right ventricle

Doppler ultrasound examination

in dogs and cats. 3. Assessment of

THIS article, the third and final instalment in a series on the role of Doppler ultrasonography in the
investigation of diseases in dogs and cats, discusses the applications of Doppler ultrasound in the
assessment of cardiac diseases. The previous articles described the Doppler principle and the different
Doppler techniques used for diagnosis (Part 1, In Practice, April 2005, pp 183-189) and the applications
of Doppler ultrasound in the abdomen (Part 2, May 2005, pp 238-247).


is Senior Lecturer in
internal medicine in
the Department of As described in Part 1, Doppler ultrasound techniques
Veterinary Clinical are based on the principle of the Doppler shift – that is, a
Sciences at The Royal
Veterinary College change in the frequency of sound that is observed when
(RVC). He is an RCVS the source is moving relative to the observer. A familiar
specialist in veterinary
cardiology and holds example of the Doppler shift is the change in pitch of the
the European College siren on a passing ambulance or police car, which is high
of Veterinary Internal (A)
Medicine’s cardiology
on approach, then becomes suddenly lower as the vehi-
diploma. His main cle moves away. In medical ultrasound, this principle
area of interest is
small animal
may be used to detect and measure the flow of blood
cardiorespiratory because red blood cells (RBCs) reflect ultrasound waves,
medicine. producing echoes that can return to the transducer. The
echoes returning from moving RBCs will have a higher
frequency than the original ultrasound pulse if the
RBCs are moving towards the transducer and a lower
frequency if the RBCs are moving away from the trans- (B)
ducer (see right). Echoes originating from stationary
objects in the body will have the same frequency as Origin of the Doppler shift in blood
vessels. (A) 5 MHz ultrasound beam
the transmitted ultrasound beam (ie, there will be no reaching red blood cells (RBCs) moving
Chris Lamb is Senior Doppler shift). away from the transducer. (B) Echoes
Lecturer in radiology originating from these moving RBCs
in the Department
The observed Doppler shift may be used to calculate
have an altered frequency because the
of Veterinary Clinical the velocity of moving RBCs, as follows: ultrasound waves are either bunched
Sciences at The RVC. together (ie, wavelength is reduced in
He is a diplomate of the same direction as flow) or spaced
both the American out (ie, wavelength is increased in the
College of Veterinary opposite direction to flow). A transducer
Radiology and the facing the approaching RBCs will receive
European College of fD.c echoes with a frequency greater than
Veterinary Diagnostic v= 5 MHz, whereas a transducer facing the
Imaging. retreating RBCs will receive echoes
with a frequency lower than 5 MHz
where v = Blood flow velocity, fD = Doppler shift,
f = Frequency emitted by transducer, c = Speed of
ultrasound propagation in tissue, cosθ = Cosine of The various Doppler techniques are summarised in
the angle between the ultrasound beam and direc- the table on page 287. The technicalities of these modali-
In Practice (2005) tion of flow (angle of insonation) ties (with the exception of Doppler tissue imaging – see
27, 286-292 later) were described in Part 1.

286 In Practice ● JUNE 2005


Continuous wave Pulsed wave

Doppler Doppler Colour Doppler Power Doppler Doppler tissue imaging

Quantitative assessment ++ + + – _
of blood flow
Global view of blood flow – – ++ ++ _
within an organ
Assessment of ventricular _ _ _ _ ++
wall motion
– Not used, + Moderately useful, ++ Optimal method



Colour Doppler, pulsed wave Doppler and continuous

wave Doppler are all used in the examination of the
heart. Colour Doppler is a convenient method for detect-
ing flow over the relatively wide area encompassed by
the two-dimensional ultrasound image, but is not an
accurate method for measuring flow velocity. It is used
primarily as a means of rapidly assessing the presence
and direction of blood flow, and then acts as a guide for
the placement of spectral Doppler sample volumes to (A) (B)
measure flow velocity (see right). Colour Doppler imag-
Use of colour Doppler
ing requires several pulses of ultrasound per scan line ultrasonography in a
in order to calculate the mean Doppler shift for each cat with a ventricular
septal defect (VSD).
sample volume. This results in a lower frame rate than (A) Two-dimensional,
is used for grey-scale imaging at a comparable depth, grey-scale image
obtained from a right
which may be a problem when attempting to examine intercostal window
flow in animals with a high heart rate or flow of a high shows the VSD as a
focal lack of echoes
velocity. A visual display of one or more full cardiac in the interventricular
cycles can be achieved using colour M-mode examina- septum (arrow).
tion, which avoids the problem of a low frame rate (see RV Right ventricle,
LV Left ventricle,
below). Simultaneous recording of an electrocardiogram LA Left atrium.
(ECG) helps to determine the point in the patient’s car- (B) Corresponding
colour Doppler image
diac cycle at which flow is occurring. shows red-coded flow
In continuous wave Doppler, echoes may originate from from the left ventricle (C)
towards the VSD,
blood flow anywhere within the region where the transmit- which turns into a multicoloured pattern through the VSD and in the right ventricle.
ted ultrasound beam overlaps with the field of view of the Inclusion of blue shades indicates that the blood flow velocity is not correctly depicted by
the colour map (a limitation known as aliasing – see Part 1). (C) Continuous wave Doppler
receiver. This is an elongated zone; hence, it is not possible
spectrum obtained using the colour Doppler image as a guide. Peak blood flow velocity
to determine accurately from what depth echoes are return- through the VSD exceeds 5·5 m/second. This is a more accurate assessment of flow velocity
ing. This limitation – known as range ambiguity – is a than was possible using the colour Doppler image. Turbulent (ie, multidirectional) flow is
indicated by simultaneous positive and negative Doppler shifts (curved arrow)
problem when attempting to determine the origin of a
Doppler signal. For example, if a high velocity is recorded
from an ultrasound beam placed through the left ventricular
outflow tract, the aortic valve and the ascending aorta range A variant of pulsed wave Doppler, known as high
ambiguity will mean that the ultrasonographer cannot dis- pulse repetition frequency (HPRF), is also useful for
tinguish (on the basis of the velocity alone) between sub- obtaining Doppler spectra from specific points within
valvular, valvular and supravalvular aortic stenosis. the heart. It is less prone to aliasing than conventional

Colour Doppler may be used

in combination with M-mode
ultrasonography, particularly
when examining the heart;
the combination of techniques
enables accurate timing of
abnormal blood flow during
the cardiac cycle. This colour
M-mode image shows
abnormal, heterogeneous
colour Doppler signals in the
left ventricular outflow tract
(LVOT) during diastole and
in the left atrium (LA) during
systole. These findings
indicate aortic insufficiency
and mitral insufficiency,

In Practice ● JUNE 2005 287


Cardiac Doppler is not an examination that is conducted

in isolation. It should be performed in conjunction with a
two-dimensional, grey-scale ultrasound examination of
the heart and interpreted in the light of the animal’s
history, clinical signs and findings from other diagnostic
The ultrasound transducer may be placed at various
positions on the thoracic wall in order to image the heart.
Some of the positions used for a two-dimensional, grey-
scale ultrasound examination of cardiac structures are
unsuitable for Doppler examination because the direc-
tion of blood flow is roughly perpendicular to the ultra-
Two-dimensional, grey-scale image illustrating the acquisition sound beam (as illustrated at the top of page 289). The
of a high pulse repetition frequency (HPRF) Doppler spectral
signal – in this case in the ascending aorta of a dog from the
maximum (true) Doppler shift is observed only when the
subcostal location. There are two sample volumes on the ultrasound beam is aligned parallel to the axis of flow.
display (arrows) and the machine will calculate the total
If the ultrasound beam is at an angle to flow, a reduced
Doppler shifts acquired simultaneously from each sample
volume without discriminating whether the acquired Doppler shift will be detected and, if the ultrasound
information relates to blood flow in the first or the second beam is perpendicular to the flow, there will be no
volume. This introduces ‘range ambiguity’. In this instance,
the ultrasonographer can reason that any flow detected is Doppler shift because blood flow is neither towards nor
unlikely to be from the sample volume closest to the away from the transducer (see Part 1). Therefore, when
transducer (nearest the top of the image) because this is
situated in the liver. The use of HPRF enables higher velocities performing a Doppler examination of the heart, the
to be measured while minimising aliasing transducer is placed in positions that optimally align the
ultrasound beam and blood flow. This maximises the
Doppler shift, making any velocity determinations more
pulsed wave Doppler, but more susceptible to range accurate, and avoids the need for angle corrections
ambiguity because it uses multiple sample volumes (as (because when θ = 0, cosθ = 1). Any misalignment of
illustrated above). As mentioned earlier, range ambiguity the ultrasound beam will lead to an underestimation
exists when there is uncertainty over the exact location of the true velocity. Thus, if the velocity is consistently
from which a velocity measurement is being taken. greater when measured from one transducer position
There is minimal range ambiguity with pulsed wave compared with another, it can be assumed that the higher
Doppler because the patient receives only one pulse of measurement is the more accurate. Optimal transducer
ultrasound at any one time; hence, the location from positions for Doppler examination of flow through the
which ultrasound echoes are returning is known. With heart valves are summarised in the table below.
HPRF, two or more pulses may be in the patient at any In animals with an abnormal thoracic conformation
one time and therefore some ambiguity exists. The (eg, pectus excavatum) or altered cardiac shape, the
advantage of HPRF is that, by more frequently sampling optimal transducer position may be different from that
the frequency of the ultrasound beam, it is less prone to used in normal animals. Therefore, when examining
aliasing at high velocities and so higher velocities can be an abnormal heart, attempts should be made to maxi-
measured using this technique. As a general rule, pulsed mise the Doppler shift by varying the transducer loca-
wave Doppler is unreliable for measuring velocities over tion and applying the rule that the maximum velocity
1·5 m/second. Higher velocities are best measured is likely to indicate the optimum alignment, in order to
using HPRF or continuous wave Doppler (see image determine which transducer position provides the best
below). measurement.



Valve to be
interrogated Optimal transducer location

Mitral valve Mitral inflow and insufficiency are best imaged from the
left apical four-chamber view

Tricuspid valve Tricuspid inflow and insufficiency can be imaged from

the right parasternal short-axis view at the level of the
heart base, the left apical four-chamber view or the left
cranial view. Optimal alignment has been described from
a modified left apical position

Pulmonic valve The optimum view is either the right parasternal short-axis
view at the level of the heart base or, in some cases, the
Doppler spectrum obtained from the pulmonary artery of a dog using a
left cranial parasternal long-axis view
continuous wave technique at 2·5 MHz. The vertical axis is Doppler shift in
kHz: positive shifts (increase in apparent frequency) represent flow towards
the transducer and negative shifts represent flow away from the transducer. Aortic valve The highest (and therefore most accurate) velocities are
The horizontal axis is time in seconds (with subdivisions every 0·2 seconds). usually obtained from the subcostal view. However, this
An ECG (green line) is used to determine the stage of the cardiac cycle. is difficult to achieve in some dogs and most cats. The left
There is high velocity systolic flow away from the transducer (1 to 3), which apical ‘five-chamber’ view can be used under these
represents the forward stroke volume, and lower velocity diastolic flow circumstances
towards the transducer (4), which is the result of pulmonic insufficiency

288 In Practice ● JUNE 2005

Blood flows from areas of high pressure to areas of
lower pressure, and the greater the pressure difference
between two points, the higher the flow velocity.
Conversely, the pressure difference between two points
Ao may be calculated from the velocity of blood flow
between them according to the modified Bernoulli

P1 – P2 = 4v2

where P1 – P2 = Pressure difference (mmHg),

v = Blood flow velocity (m/second)

Diagram illustrating that optimal orientation of the

transducer for two-dimensional, grey-scale ultrasound To illustrate the use of the modified Bernoulli equa-
examination of the heart may result in blood flow
(yellow arrows) being perpendicular to the direction
tion, imagine that the peak blood flow velocity measured
of the ultrasound beam (red arrow). A transducer position across the aortic valve during systole is 4 m/second. This
that is suitable for a two-dimensional examination of a means that the pressure difference between the left ven-
valve is not necessarily suitable for Doppler interrogation
of flow at that valve tricle (P1) and the aorta (P2) is 4 x 42 – ie, 64 mmHg.
This is increased, consistent with moderate aortic steno-
sis. Note that it is only the pressure difference that can
be estimated from the Doppler examination. Certain
CHARACTERISTICS OF FLOWING BLOOD assumptions are required in order to infer absolute pres-
sures within cardiac chambers.
The normal cardiac cycle is a series of rapid, coordinated Blood flow normally occurs at specific stages of the
events, which smoothly propel blood in one direction cardiac cycle. Abnormal blood flow may be detected if
through the cardiac chambers and great vessels. it occurs at the wrong time. For example, flow across the
Abnormal intracardiac blood flow may be recognised aortic valve is not expected in diastole, and is an indica-
during a Doppler examination when: tion of aortic insufficiency.
■ Flow occurs in the wrong direction; The duration of blood flow may be abnormal. For
■ Flow velocity is outside the normal range; example, the duration of left ventricular ejection may be
■ Flow occurs at the wrong stage of the cardiac cycle; abnormally short when the myocardium is weak. Also
■ The duration of flow is outside the normal range. the duration or relative duration of different components
The direction of blood flow within the heart may be of flow may be abnormal. For example, prolonged decel-
altered because of disease. For example, mitral insuffi- eration of the first or early component of mitral inflow
ciency allows blood to pass from the left ventricle to the may be associated with narrowing of the mitral valve or
left atrium during systole. Blood flow velocity may be impaired relaxation of the left ventricular myocardium
decreased in an animal with a weak myocardium (eg, as (see later).
a result of dilated cardiomyopathy) or increased in an
animal with a lesion resulting in narrowing of a vessel
(eg, aortic or pulmonic stenosis). In animals with EXAMPLES OF ABNORMAL
valvular stenosis, the appearance of the Doppler CARDIAC DOPPLER RESULTS
spectrum changes because blood flow through the
stenotic region has an increased velocity, which leads to Aortic valve
turbulence. Turbulence may be recognised by the Flow across the aortic valve should only occur during
presence of bidirectional flow, which appears on both systole. Significant aortic insufficiency – which occurs
sides of the baseline in a Doppler spectrum (see during diastole – is rarely observed in dogs, but can
below). accompany congenital aortic stenosis or may be acquired

(A) Plug flow (B) Disturbed flow

The appearance of the Doppler spectrum varies according to the type of blood flow. (A) In the ascending aorta there is normally plug flow, in which all the
RBCs accelerate and decelerate together, so the Doppler spectrum is a line with a lack of signal (*) beneath it. This type of pattern will only be seen using
pulsed wave Doppler where the sample volume is relatively small. (B) In vessels containing disturbed flow (eg, as a result of stenosis), the Doppler spectrum
will show an increased peak systolic velocity (large arrow) and a signal below the baseline (small arrow), which occurs because of turbulence. In this
example, the late peak in velocity and shape of the velocity trace suggest that the peak velocity, and therefore greatest pressure gradient, develops in
late systole; this indicates the presence of a dynamic stenosis, as can be seen in cases of hypertrophic obstructive cardiomyopathy

In Practice ● JUNE 2005 289

(A)O) (B)
Aortic insufficiency. (A) Long-axis and (B) short-axis two-dimensional,
grey-scale images of the root of the aorta of a dog with endocarditis in
which the aortic valve leaflets are hyperechoic, thickened and misshapen.
(C) Continuous wave Doppler spectrum obtained from the aorta (using a
subcostal window through the liver) showing high velocity flow (1 to 3) away
from the transducer in systole and a similar high velocity flow towards the
transducer in diastole (*). The Doppler spectrum indicates both aortic stenosis (C)
and aortic insufficiency as a result of the valvular lesions

secondarily to endocarditis (see above). The most com-

mon condition affecting the canine left ventricular out-
flow tract is aortic stenosis. This is characterised by an QAVC
increased aortic outflow velocity, usually exceeding 2 m/
second (>5 m/second in severe cases).
A normal aortic outflow velocity can be used in con-
junction with a simultaneously recorded ECG to calcu-
late the systolic time intervals – which, in turn, can give
an indication of systolic function (see right).

Mitral inflow patterns

The diagrams below illustrate the normal mitral inflow pattern, and potential
alterations in mitral flow associated with diastolic dysfunction of the left ventricle. Measurement of systolic time intervals. Using the
spectral Doppler trace of aortic outflow, the duration of
electromechanical events in systole can be quantified. The
E total duration of electromechanical systole corresponds to
the period from the onset of the Q wave on the ECG to the
closure of the aortic valve (indicated by the cessation of
flow). This period is known as ‘Q to aortic valve closure’
E (QAVC). This in turn consists of two periods: the pre-ejection
period (PEP), from the onset of the Q wave to the onset of
A flow; and the left ventricular ejection time (LVET), from
the onset of flow to the end of flow. Evaluation of these
intervals, and in particular the ratio of PEP to LVET,
can assist in the assessment of systolic function

Mitral valve
Flow across the mitral valve should be diastolic. It typical-
Normal pattern Delayed relaxation Restrictive filling
ly occurs in two phases: the early filling, or E wave, and
The normal pattern Delayed relaxation of A restrictive
the late filling secondary to atrial contraction, or A wave.
of flow is characterised the myocardium leads filling pattern is
The relative magnitude and duration of these waves can be
by a relatively rapid to a reduction in the characterised by
used to characterise diastolic function of the left ventricle.
acceleration of blood magnitude of the the majority of the
Mitral stenosis is a relatively rare congenital condition
into the left ventricle E wave, more gradual ventricular filling
in which the mitral inflow velocities may alter in their mag-
during passive deceleration of flow occurring during
nitude or duration (see box on the left and image below).
ventricular filling to and thus prolongation early diastole. The
a peak inflow velocity, of the slope. E wave is increased
followed by a relatively Atrial contraction in magnitude but
rapid deceleration. contributes a relatively decreased in duration.
This gives rise to greater proportion of The A wave is
the E wave. Atrial ventricular filling – relatively decreased
contraction then therefore, the A wave in magnitude.
produces a second may be greater in
peak of inflow (A magnitude than the
wave). The magnitude E wave. Prolongation
Mitral stenosis in a young dog. This pulsed wave Doppler
of the peak velocity of of the slope is also spectrum shows the characteristic biphasic inflow velocities
the A wave should be seen with narrowing consisting of the E wave (E) and A wave (A). In this instance,
there is prolonged deceleration of the E wave, which
less than that of the of the mitral valve or
indicates delayed equilibration of atrial and ventricular
E wave. mitral stenosis. pressures in diastole. In combination with other clinical
and echocardiographic findings, this appearance supports
a diagnosis of mitral stenosis

290 In Practice ● JUNE 2005

Mitral insufficiency (ie, systolic regurgitation of In animals with an ASD, flow can be demonstrated
blood back across the valve) is a very common acquired between the atria. This flow is usually non-turbulent
condition with a number of possible causes. Most com- because of the low pressures within normal atria. When
monly in dogs it occurs because of myxomatous degen- an ASD is suspected, colour Doppler examination is use-
eration of the valve, but it may also develop as a result ful because a lack of echoes from the interatrial septum
of dilated cardiomyopathy, congenital malformation, (‘echo dropout’) during a two-dimensional, grey-scale
endocarditis or hypertrophic cardiomyopathy (in cats). ultrasound examination could be misinterpreted as an
The velocity of mitral insufficiency jets is best measured ASD. As mentioned above, if there is a significant
from the left apical location and typically exceeds defect, and a moderate to large volume of blood is shunt-
5 m/second due to the large pressure difference that ing from left to right, then an increased pulmonary out-
normally exists between the left ventricle and left atrium flow velocity may be expected.
during systole. Velocities significantly lower than this Blood flow through a patent ductus arteriosus (PDA)
will usually indicate either high left atrial pressure, low has a characteristic pattern that is continuous but vari-
left ventricular pressure, poor technique or a weak signal able, with its peak in systole. This pattern of flow gives
due to the insufficiency jet being small. Some informa- rise to a Doppler spectrum with a typical ‘sawtooth’
tion regarding left ventricular function may be obtained appearance (see below). Flow through a PDA is usually
from the slope of the upstroke of a mitral insufficiency most clearly visible from a left parasternal cranial long-
jet, in that it provides an indication of the rate of change axis view. In many affected dogs, the ductus arteriosus
of left ventricular pressure. itself may be seen on two-dimensional, grey-scale and
colour Doppler examination.
Pulmonic valve
Like the aortic valve, flow across the pulmonic valve
should normally occur during systole. However, unlike
the aortic valve, small amounts of pulmonic insufficien-
cy are quite a common finding in ‘normal’ animals. Patent ductus arteriosus (PDA).
Pulmonic stenosis is characterised by an increase in (A) This two-dimensional,
pulmonary outflow velocity. Left-to-right shunting grey-scale image is a left
parasternal view obtained
intracardiac diseases (ie, atrial septal defects [ASDs] and from a window in a relatively
ventricular septal defects [VSDs]) will result in an cranial location on the
thoracic wall. The three main
increased right ventricular stroke volume and what structures illustrated are the
is known as ‘relative’ pulmonic stenosis. A high velo- pulmonary artery (PA),
descending aorta (Ao) and
city pulmonic insufficiency jet (>2·2 m/second) can indi- PDA. (B) The same image
cate the presence of high pulmonary artery diastolic with colour Doppler
superimposed. Flow
pressure and thus signify the presence of pulmonary (A) in the pulmonary artery is
hypertension. predominantly blue (ie, away
from the transducer). Flow in
the ductus arteriosus is red
Tricuspid valve (ie, towards the transducer).
It is not uncommon for ‘normal’ dogs to show a small Where the ductus narrows
and empties into the
amount of tricuspid insufficiency. Where large tricuspid pulmonary artery,
insufficiency jets are found, this may be due to tricuspid acceleration of flow leads
to a jet of turbulent flow,
dysplasia (in young animals) or acquired tricuspid in- which appears as a mixture
sufficiency. The latter often accompanies degenerative of high intensity colours in
mitral insufficiency in older animals and becomes the pulmonary artery.
(C) This spectral Doppler trace
particularly significant if pulmonary hypertension dev- acquired from the ductus
elops in the later stages of the disease. A high velo- arteriosus shows continuous,
high velocity flow towards
city (>2·8 m/second) tricuspid insufficiency jet is an the transducer throughout
indication of increased right ventricular systolic pres- (B) systole and diastole in a
typical ‘sawtooth’ pattern
sure. In the absence of pulmonic stenosis this suggests
the presence of pulmonary hypertension. Elevated or
prolonged tricuspid inflow velocities may be indicative
of tricuspid stenosis, which is a relatively rare congenital

Non-valvular locations at which abnormal flow

may be recorded
Septal defects may result in abnormal blood flow in a
non-valvular location. A VSD is associated with flow
across the interventricular septum, typically just beneath
the aortic valve in the region of the ‘membranous’ sep-
tum (as illustrated on page 287). The velocity of the jet
(assuming it is accurately measured) may be used as an
aid to prognosis. A high velocity jet implies the septal
defect is fairly small and the pressure difference between
the right and left ventricle is maintained. It is suggested
that VSDs with a trans-septal flow velocity of >4 m/
second carry a fair prognosis.

In Practice ● JUNE 2005 291

Echo amplitude
Tissue Contrast Tissue Contrast

Low amplitude

Low velocity filter Velocity
(A) (B)

Principle of Doppler tissue imaging.

Doppler signals from moving tissues,
flowing blood and intravascular ultrasound
contrast medium may be distinguished on
the basis of the amplitude of their echoes
and their velocity. (A) In conventional
Doppler ultrasound, a filter is used to
remove low velocity signals that arise
from movement of the blood vessel wall
and other structures. If not removed, these
high amplitude signals (‘wall thump’)
may drown the weaker signals from RBCs.
(B) For Doppler tissue imaging, a filter
is used to remove the low amplitude
signals from blood. In a patient without
intravascular ultrasound contrast medium,
the remaining Doppler signals originate
from moving tissues, such as the
myocardium. (C) Example of M-mode
Doppler tissue imaging in a healthy
whippet. Blue hues indicate movement of
the myocardium away from the transducer
and red hues indicate movement towards
the transducer


DOPPLER TISSUE IMAGING in the cardiac cycle and, in some cases, to characterise
systolic and diastolic function of the myocardium. The
As discussed in this series of articles, Doppler ultrasound major application of this technique is assessment of
is used mostly to detect echoes from RBCs, which are myocardial infarction in human patients, but it may also
very weak compared with echoes from tissue. Weak prove to be useful in the assessment of dogs and cats with
echoes from blood – particularly in small or deeply situ- cardiomyopathy.
ated blood vessels – may be boosted by administering
Further reading
an intravenous ultrasound contrast medium containing A detailed description of the various techniques of cardiac Doppler
microbubbles, which are strong reflectors of ultrasound. examination is outside the scope of this article. Interested readers
are referred to the following texts for further information:
It is also possible to measure the Doppler shift of echoes GOLDBERG, S. J., ALLEN, H. D., MARX, G. R. & DONNERSTEIN, R. L.
returning from moving tissues, such as the myocardium. (1988) Doppler Echocardiography, 2nd edn. Philadelphia, Lea &
Doppler tissue imaging uses a filter to remove the rela- MARCUS, M. L., SCHELBERT, H. R., SKORTON, D. J. & WOLF, G. L.
tively weak echoes from flowing blood (as illustrated (1996) Cardiac Imaging; A Companion to Braunwald’s Heart
Disease, 2nd edn. Philadelphia, W. B. Saunders
above). This specialised technique is used to measure the NYLAND, T. G. & MATTOON, J. S. (2001) Veterinary Diagnostic
timing, magnitude and direction of myocardial movement Ultrasound, 2nd edn. Philadelphia, W. B. Saunders

292 In Practice ● JUNE 2005