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How to Obtain a Good Echocardiography Examination: Ultrasound Physics, Technique, and Medical Knowledge

FIG1.1

The burgeoning technologic revolution of the past two decades has produced a continuous evolution in the denition of a complete and comprehensive echocardiographic evaluation (Fig. 1-1). Echocardiography is now a fully grown tree. It has numerous clinical applications, with various forms of ultrasound technology being used throughout the entire eld of cardiovascular medicine. This mature ultrasound tree has grown from a seed planted more than 50 years ago. Since then, the tree has been trimmed and nourished carefully by many pioneers to serve the needs of patients and clinicians. In 1954, Edler and Hertz (1) of Sweden were the rst to record movements of cardiac structures, in particular, the mitral valve, with ultrasound. In the early 1960s in the United States, Joyner and Reid (2) at the University of Pennsylvania were the rst to use ultrasound to examine the heart. Shortly afterward, in 1965, Feigenbaum and colleagues (3) at Indiana University reported the rst detection of pericardial effusion with ultrasound and were responsible for introducing echocardiography into the clinical practice of cardiology. However, M-mode

echocardiography produced only an ice pick view of the heart; two-dimensional (2D) sector scanning, developed in the mid-1970s, allowed real-time tomographic images of cardiac morphology and function (4). The rst phased array 2D sector scan at Mayo Clinic was made on March 17, 1977. Although the development of Doppler echocardiography paralleled that of M-mode and 2D echocardiography from the early 1950s, it was not used clinically until the late 1970s. Pressure gradients across a xed orice could be obtained reliably with blood-ow velocities recorded by Doppler echocardiography. Two groups, Holen and colleagues (5) and Hatle and colleagues (6), should be credited for introducing Doppler echocardiography into clinical practice. Numerous validation studies subsequently conrmed the accuracy of Doppler echocardiography in the assessment of cardiac pressures. Therefore, the Doppler technique made echocardiography not only an imaging but also a hemodynamic technique. On the basis of the Doppler concept, color ow imaging was developed in the early 1980s so that blood ow could also be visualized noninvasively (7).

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Chapter 1

Time

Period

Figure 1-2 Diagram of a sound wave. A, amplitude.

more. All sound waves (Fig. 1-2) are characterized by the following seven variables (15): frequency ( f ), wavelength (), period (p), speed (s), amplitude (A), power, and intensity. f = the number of cycles per second; 1 cps is 1 Hz. = the length of one complete cycle of the sound; its usual unit of measure is millimeters (mm). s = the speed or velocity of sound waves through a medium is equal to the product of f and (s = f ) and is determined by the characteristics of the medium. Speed is not affected by the frequency of sound. The average speed of sound in soft tissue is 1,540 m/s. p = the time duration of 1 cycle; hence, 1 s/f = p or f p = 1. A = the magnitude of a sound wave, the maximum change from the baseline. Power is the rate at which energy is transferred from a sound beam, in watts (W), and is proportional to the amplitude squared (15). Intensity is the concentration of energy in a sound beam and equals power divided by its cross-sectional area. Sound waves can be combined to create one wave. Thus, two in-phase (or superimposed) waves create a wave with a larger amplitude, and two out-of-phase (or mirror-image) waves create a wave with a smaller amplitude or the two waves cancel each other if they have the same amplitude. This phenomenon is called interference (15). It is used in pulse-inversion and pulse-modulation techniques for harmonic imaging and contrast echocardiography. At the start of an echocardiography examination, the appropriate transducer is selected according to the type of examination and patients body habitus. A higher frequency transducer provides better resolution, but it has a shallower depth of penetration. For the pediatric population, the transducer frequency is usually 5 to 7.5 MHz (1 MHz = 1million cps), but for adults the transducer frequency at the start of an examination is usually 2 to 2.5 MHz and occasionally 5 MHz for patients with a thin chest wall. The transducer consists of piezoelectric elements that convert electrical energy to ultrasound and vice versa. Electrical energy is applied to the transducer in pulses with a dened pulse repetition frequency (PRF in kilohertz [kHz]), producing ultrasound waves at dened, regular intervals of pulsed repetition period. The wavelength of the ultrasound generated is related to the thickness of the piezoelectric elements. The thinner the elements, the shorter the wavelength. Because the product of wavelength

FIG1.2

Figure 1-1 Echocardiography has become a mature tree that has numerous branches and is still growing. CFI, color ow imaging; ICUS, intracardiac ultrasonography; I-Op, intraoperative echocardiography, IVUS, intravascular ultrasonography; TEE, transesophageal echocardiography; 3D/4D, three- and four-dimensional echocardiography.

Another ingenious modication of Doppler echocardiography was tissue Doppler imaging (TDI), which allows echocardiographers to record myocardial tissue velocity and to measure the extent of myocardial deformation as strain (8,9). These measurements provide a sensitive assessment of systolic and diastolic function and are becoming a standard component of a comprehensive echocardiography examination. Widespread clinical use of transesophageal echocardiography (TEE) began in 1987 (10), and the subsequent development of intravascular and intracardiac high-frequency transducers has permitted extraordinarily detailed imaging and hemodynamic assessment of the cardiovascular system. Most recently, three-dimensional (3D) echocardiography has become a reality. It provides a more realistic depiction of cardiovascular structures and more accurate volumetric quantitation (11,12). With these technologic advances, the application of echocardiography has been spreading into numerous clinical areas, including the evaluation of diastolic function, stress echocardiography, intraoperative echocardiography, fetal echocardiography, contrast echocardiography, intracardiac imaging, and vascular imaging. The size of the ultrasound unit is becoming smaller, and some units can be hand-carried to the patients bedside (13,14). We are fortunate to have this versatile diagnostic modality to provide reliable structural, functional, and hemodynamic information about the cardiovascular system of our patients.

ULTRASOUND AND TRANSDUCER

Echocardiography uses ultrasound to create real-time images of the cardiovascular system in action. Ultrasound represents sound waves with a frequency of 20,000 Hz or

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How to Obtain a Good Echocardiography Examination: Ultrasound Physics, Technique, and Medical Knowledge

() and sound frequency ( f ) is the speed of the sound in the tissue ( f = 1, 540 m/s), sound frequency is related inversely to the thickness of the piezoelectric elements. These transducer elements need to move to generate multidirectional ultrasound beams. This movement can be achieved mechanically or electronically. Although a mechanical transducer can produce multiple imaging lines from a small transducer area, the ultrasound beam diverges more the deeper it penetrates tissue. In an electronic transducer, multiple piezoelectric elements are arranged in a straight line and sound beams are steered and focused electronically. Most of the current ultrasound units have electronic steering, with phased stimulation of the piezoelectric elements. Because image resolution is better with shorter wavelengths, a higher frequency transducer produces an image with better resolution but shallower penetration. Technology has advanced to the point that a transducer contains 3,000 piezoelectric elements to create a matrix transducer, which allows real-time 3D imaging. In fundamental imaging, echocardiographic images are created when the transducer receives reected beams of the same frequency as the transmitted beam, but the interface between tissue and blood can be delineated better with the reception of harmonic frequencies. Harmonic imaging has developed directly from arduous attempts to improve the ultrasound imaging of contrast microbubbles. When contrast microbubbles are imaged, the bubbles resonate and produce harmonic frequencies (i.e., equivalent to multiple of the transmitted frequency). When the only reected frequency received to create the ultrasound image is equal to a multiple (2f , 3f , . . .) of the transmitted frequency, images of contrast microbubbles are preferentially produced (contrast harmonic imaging). Like microbubbles, myocardial tissues are able to generate harmonic frequencies, and harmonic imaging improves the delineation of the endocardial border (tissue harmonic imaging). As a result, harmonic imaging is usually the imaging modality of choice not only for contrast echocardiography but also for a standard echocardiography examination. Additional modications of harmonic imaging include pulse inversion and power modulation imaging, which improved resolution in contrast imaging. A limitation of harmonic imaging in routine 2D echocardiography is the increased sparkling quality to the ultrasound image and the increased thickness of the endocardial border. If the image quality is not optimal in spite of all measures, including harmonic imaging, then a contrast agent should be injected intravenously to improve the denition of the endocardial border. Because intravenous access is required, a qualied member of an intravenous team should be available to start an intravenous line as soon as contrast echocardiography is needed.

Figure 1-3 Still frame of a typical echocardiography monitor screen. It is essential for the screen to display the patients identication, blood pressure (BP ), and cardiac rhythm. The type of transducer, eld depth, color map, and other machine settings are also displayed. In the example here, the BP was 120/52 mm Hg, with a wide pulse pressure. Aortic valve shows doming (arrow ) during systole (a break in the ECG at the bottom indicates the timing of the image on the screen), with moderately severe aortic regurgitation that explains the wide pulse pressure. H3.5 MHz indicates harmonic imaging with a 3.5-MHz transducer. Field depth is 160 mm (this information is important in stress echocardiography and other quantitative studies for which the same depth is desired for all images). MI indicates mechanical index, which is an essential function in contrast echocardiography. Store in progress indicates that the echocardiographic images are stored digitally while the phrase is shown on the screen; thus, desired images need to be maintained during this period. HR, heart rate.

according to the clinical objectives of the examiner. The following should be shown on the screen: the patients identication, blood pressure at the time of the examination, and a sharp electrocardiographic tracing with prominent R and A waves (Fig. 1-3 and 1-4). Depth, size, and gain settings of the ultrasound images need to be adjusted frequently during the examination. To develop an initial impression of the overall cardiac structure and

FIG1.3 FIG1.4

SCREEN DISPLAY AND KNOB SETTINGS

How best to display echocardiographic images on the screen is a personal choice and should be choreographed

Figure 1-4 Initial parasternal long-axis view with an imaging depth of 24 cm (240 mm on screen) demonstrating a large pleural effusion (PL) and pericardial effusion (PE ). Lesions in the descending aorta (*) can also be appreciated with a long imaging depth. LA, left atrium; LV, left ventricle; RV, right ventricle.

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Chapter 1

function, the examination of an adult patient usually begins with a depth of 20 to 25 cm and a wide sector (90 degrees). This also gives an idea about any unusual extracardiac structures (Fig. 1-4). After the initial view, adjust the eld depth to use the entire screen to demonstrate the intended cardiovascular images. A zoom or regional expansion selection (RES) function should be used frequently to visualize a region of interest in more detail. The zoomed image is also better for making quantitative measurements, with less intraobserver and interobserver variability. When quantitative measurements are made, review the acquired image in a cine loop format to identify a frame at a specic timing of a cardiac cycle. Examples are a mid-systolic frame to measure the diameter of the left ventricular outow tract, an end-systolic frame to measure the size of the left atrium, and an end-diastolic frame to measure the wall thickness of the left ventricle. After an overview, specic areas need to be imaged and it may be necessary to decrease the sector size, which will improve temporal resolution by increasing the frame rate. The gain of the image is controlled by overall gain and regional gain (by time gain compensation [TGC]). As sound waves travel through a medium (e.g., tissue or blood), the intensity weakens or attenuates. The degree of attenuation is expressed in decibels (dB). Absorption represents a conversion of sound energy to another form of energy and is the major reason for attenuation. Therefore, attenuation is determined by ultrasound frequency and tissue depth. Attenuation is also greater for high-frequency sounds, which result in higher absorption and more scatter. Total attenuation is calculated by multiplying the attenuation coefcient by the length of imaged tissue. TGC allows amplication of ultrasound beams from deeper depths because different amplitudes of ultrasound signals are produced when received from different depths. More TGC is required for higher frequency transducers, which create more attenuation. Compression also reduces the differences between the smallest and largest amplitudes of ultrasound images by reducing the total range without altering the signal ratio. Once 2D images are optimized, color ow imaging is turned on to visualize the intracardiac blood ow characteristics and to identify any turbulent ow within the heart. Occasionally, color ow imaging demonstrates hemodynamic or structural abnormalities that are not readily apparent with 2D echocardiography alone. When color ow imaging is used to show a regurgitant jet, the color map aliasing velocity should be set as high as possible (by moving the velocity scale up as far as possible). The color gain should be increased to the point that it just begins to create background noise and then decreased to the level that optimizes color ow imaging of blood ow. The size of the color ow sector should be optimized because the frame rate for color ow imaging is inversely proportional to the area of imaging. The location and size of color ow imaging can be adjusted according to the objectives of the examination. If 2D or color ow imaging (or both) identies an area of

concern, a further quantitative assessment is made, such as measuring the size of the lesion, calculating the area of the stenotic or regurgitant orice, or calculating the pressure gradient. Even without the presence of obvious structural or functional abnormalities, several areas of the heart need to be interrogated to assess systolic and diastolic function. Therefore, a pulsed wave Doppler examination follows and complements color ow imaging. A pulsed wave Doppler examination of the left ventricular outow tract and the mitral leaet tips is routinely performed to calculate stroke volume and to assess diastolic function, respectively. Other relatively routine pulsed Doppler examinations include the right ventricular outow tract, pulmonary vein, hepatic vein, upper descending aorta, and abdominal aorta. A comprehensive echocardiography examination should include a continuous wave Doppler examination of the descending aorta to assess for the presence of coarctation, especially in patients who have hypertension or a bicuspid aortic valve. Another important area of a pulsed wave Doppler examination is the mitral anulus, but the Doppler mode needs to be changed to TDI. Pulsed wave Doppler has been modied to record velocity from the tissues which is lower in absolute velocity but higher in amplitude. When TDI or myocardial imaging is selected, higher tissue velocities are ltered out and only lower tissue velocities, usually 5 to 20 cm/s, are recorded. Because of the higher amplitude, the gain needs to be decreased when the examination is switched from regular pulsed wave Doppler imaging to TDI. TDI has numerous applications (see Chapter 4). It is essential in evaluating cardiac function (systolic and diastolic) and the timing of cardiac events, and it is useful in assessing mechanical dyssynchrony among different regions of the left ventricle (16,17). Myocardial strain and strain rate can be derived from TDI (18). Tissue tracking and tissue synchronization imaging (TSI) have been developed to allow echocardiographers to assess the pattern and timing of myocardial contraction readily with color imaging of tissue Doppler velocities. During a Doppler examination, the recording of velocity is optimized by selecting or adjusting the velocity scale, gain, baseline position, sweep speed, sample volume size, and respiratory cycle. Recording space should be used fully by selecting the highest velocity to be about 25% higher than the obtained velocity. For example, if aortic stenosis velocity is 4 m/s, it is better to have the highest velocity scale set at 5 m/s instead of 7 m/s. If pulmonary vein peak velocity is 80 cm/s, it is better to have the Nyquist limit or aliasing velocity at 120 cm/s instead of 200 cm/s. The baseline can be shifted accordingly to demonstrate fully the obtained or desired recorded velocity. Initial Doppler gain should be increased to the point of background noise and then decreased to produce optimal contrast with the recorded signal. Colorization of the Doppler signal frequently makes the velocity sharper and is available on most machines by pushing or selecting that option. The smallest possible sample volume size (12 mm) usually is selected to record

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How to Obtain a Good Echocardiography Examination: Ultrasound Physics, Technique, and Medical Knowledge

the pure velocity signal from the region of interest when a slight variation in sample volume location can produce different velocities, as in the left ventricular outow tract or mitral leaet tips. However, a larger sample volume size (35 mm) may be necessary to obtain a good velocity signal from an area of interest that is small, as in a pulmonary vein, or hepatic vein, or during tissue Doppler imaging of the mitral anulus. Color ow imaging is helpful as a guide for locating the ideal site for placing a sample volume. When the region of interest moves with the cardiac cycle or with respiration, a signal may be obtained by instructing the patient to hold his or her breath or by slightly changing the location of the sample volume during several attempts to obtain the signal. The sweep speed is usually set at 50 mm/s for recording Doppler velocities, but when time intervals are measured, it may be increased to 100 mm/s. When multiple cardiac cycles need to be recorded together, the sweep speed is reduced to 25 mm/s, especially when the respiratory variation of Doppler velocity is assessed. Because contrast can dramatically enhance weak Doppler signals, it should be considered for improving the accuracy of the examination of patients who have weak tricuspid regurgitation or an aortic stenosis jet.

start echocardiographic training by developing technical expertise, and others approach this training after medical school or residency. The miniaturization and portability of echocardiographic machines may provide a strong incentive for physicians to learn technical and interpretive skills of ultrasonography during medical school (13) or residency, akin to learning about heart sounds by using a stethoscope. Sonographers take a different road to sonography, approaching echocardiography by learning and perfecting technical skills. When a sonographer understands which echocardiographic parameters are important for a specic clinical diagnosis or for the patients symptoms and why, he or she is truly an accomplished echocardiographer. Therefore, the echocardiography examination should integrate the medical and sonographic skills to produce clinically relevant and visually attractive echocardiograms. Physician training requirements for the performance and interpretation of adult transthoracic echocardiography examinations have been developed by the ACC/AHA Task Force on competence in collaboration with the American Society of Echocardiography, the Society of Cardiovascular Anesthesiologists, and the Society of Pediatric Echocardiography (Table 1-1) (20). There are three levels of physician training: Level 1 training is dened as the minimal introductory training that must be achieved by all trainees in adult cardiovascular medicine. This includes a basic understanding of the physics of ultrasound, the fundamental technical aspects of the examination, cardiovascular anatomy and physiology related to echocardiographic and Doppler imaging, and recognition of simple and complex cardiac abnormalities and their pathophysiology. Level 2 training is the minimum recommended training for a physician to perform echocardiography and to interpret echocardiograms independently. Level 3 training requires at least 12 months of training that provides a level of expertise sufcient to enable a physician to serve as director of an echocardiography laboratory and to be directly responsible for quality

TAB1.1

GOAL-DIRECTED AND COMPREHENSIVE EXAMINATION BY WELL-TRAINED PERSONNEL

To perform a clinically pertinent echocardiography examination, it is important to have a strategy to determine which of the numerous echocardiographic views and parameters will provide the optimal information for assessing the patient being examined. A strategy is best formulated after the examiner (sonographer or physician) has a clear understanding of the clinical problem or problems to be evaluated. An echocardiography examination is highly useful clinically and cost-effective when sound medical knowledge is combined with sound technical skills, including an understanding of ultrasound physics (15,19) and the instrumentation, and interpretive skills. Some

TABLE 1-1
TRAINING REQUIREMENTS FOR THE PERFORMANCE AND INTERPRETATION OF ADULT TRANSTHORACIC ECHOCARDIOGRAPHY EXAMINATIONS
Cumulative duration of training, mo
Level 1 Level 2 Level 3 3 6 12

Minimum total number of examinations performed

75 150 (75 additional) 300 (150 additional)

Minimum number of examinations interpreted

150 300 (150 additional) 750 (450 additional)

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Chapter 1

control and for training sonographers and physicians in echocardiography.

systolic pressure. Typical echocardiography reports from the Mayo Clinic laboratory are shown in the Appendix.

DIGITAL ECHOCARDIOGRAPHY
Digital echocardiography has profoundly changed and improved the practice of echocardiography (21). It is extremely convenient to acquire, transmit, and review echocardiographic images digitally. However, because only a limited number of cardiac cycles usually are acquired, it is essential for examiners to capture the most representative cardiac cycles. The number of cardiac cycles for image acquisition can be adjusted. One cycle is most economical for storage space, but it may not be representative, especially if the underlying rhythm is not regular. Acquisition of more cardiac cycles increases the time and storage space of the study. If the patient has normal sinus rhythm, a good compromise is to capture two or three cardiac cycles. However, one cardiac cycle is better for stress echocardiography because each view is compared with other images simultaneously side by side. If the patient has atrial brillation, three to ve cardiac cycles should be acquired. Digital imaging exposes the ultrasound system to the risk of viruses, worms, and parasites of the electronic system. To maintain the function of the machine and the security of patient information, the ultrasound unit needs to be protected against these electronic hazards.

REFERENCES
1. Edler I, Hertz CH. The use of ultrasonic reectoscope for the continuous recording of the movements of heart walls. 1954. Clinical Physiology and Functional Imaging, 2004;24:118136. 2. Joyner CR Jr, Reid JM. Applications of ultrasound in cardiology and cardiovascular physiology. Progress in Cardiovascular Diseases, 1963;5:482 497. 3. Feigenbaum H, Waldhausen JA, Hyde LP. Ultrasound diagnosis of pericardial effusion. JAMA: the Journal of the American Medical Association, 1965; 191:711714. 4. Tajik AJ, Seward JB, Hagler DJ, et al. Two-dimensional real-time ultrasonic imaging of the heart and great vessels: Technique, image orientation, structure identication, and validation. Mayo Clinic Proceedings, 1978;53:271303. 5. Holen J, Aaslid R, Landmark K, et al. Determination of pressure gradient in mitral stenosis with a non-invasive ultrasound Doppler technique. Acta Medica Scandinavica, 1976;199:455460. 6. Hatle L, Brubakk A, Tromsdal A, et al. Noninvasive assessment of pressure drop in mitral stenosis by Doppler ultrasound. British Heart Journal, 1978; 40:131140. 7. Omoto R, Kasai C. Physics and instrumentation of Doppler color ow mapping. Echocardiography, 1987;4:467483. 8. McDicken WN, Sutherland GR, Moran CM, et al. Colour Doppler velocity imaging of the myocardium. Ultrasound in Medicine and Biology, 1992;18:651654. 9. Heimdal A, Stoylen A, Torp H, et al. Real-time strain rate imaging of the left ventricle by ultrasound. Journal of the American Society of Echocardiography, 1998;11:10131019. 10. Seward JB, Khandheria BK, Oh JK, et al. Transesophageal echocardiography: Technique, anatomic correlations, implementation, and clinical applications. Mayo Clinic Proceedings, 1988;63:649680. 11. Zamorano J, Cordeiro P, Sugeng L, et al. Real-time three-dimensional echocardiography for rheumatic mitral valve stenosis evaluation: An accurate and novel approach. Journal of the American College of Cardiology, 2004;43:20912096. 12. Kuhl HP, Schreckenberg M, Rulands D, et al. High-resolution transthoracic real-time three-dimensional echocardiography: Quantitation of cardiac volumes and function using semi-automatic border detection and comparison with cardiac magnetic resonance imaging. Journal of the American College of Cardiology, 2004;43:20832090. 13. Wittich CM, Montgomery SC, Neben MA, et al. Teaching cardiovascular anatomy to medical students by using a handheld ultrasound device. JAMA: the Journal of the American Medical Association, 2002;288:1062 1063. 14. Seward JB, Douglas PS, Erbel R, et al. Hand-carried cardiac ultrasound (HCU) device: Recommendations regarding new technology: A report from the Echocardiography Task Force on New Technology of the Nomenclature and Standards Committee of the American Society of Echocardiography. Journal of the American Society of Echocardiography, 2002;15:369373. 15. Edelman SK, ed. Understanding Ultrasound Physics: Fundamentals and Exam Review, 2nd ed. Woodlands, TX: ESP, 1994. 16. Ommen SR, Nishimura RA, Appleton CP, et al. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular lling pressures: A comparative simultaneous Dopplercatheterization study. Circulation, 2000;102:17881794. 17. Oh JK, Tajik J. The return of cardiac time intervals: The phoenix is rising. Journal of the American College of Cardiology, 2003;42:14711474. 18. Urheim S, Edvardsen T, Torp H, et al. Myocardial strain by Doppler echocardiography: Validation of a new method to quantify regional myocardial function. Circulation, 2000;102:11581164. 19. Kremkau FW, ed. Diagnostic Ultrasound: Principles and Instruments, 6th ed. Philadelphia: W.B. Saunders, 2002. 20. Quinones MA, Douglas PS, Foster E, et al. American College of Cardiology, American Heart Association, American College of Physicians-American Society of Internal Medicine, American Society of Echocardiography, Society of Cardiovascular Anesthesiologists, Society of Pediatric Echocardiography. ACC/AHA clinical competence statement on echocardiography: A report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. Journal of the American College of Cardiology, 2003;41:687708. 21. Hansen WH, Gilman G, Finnesgard SJ, et al. The transition from an analog to a digital echocardiography laboratory: The Mayo experience. Journal of the American Society of Echocardiography, 2004;17:12141224.

ECHOCARDIOGRAPHY REPORT
Ideally, the echocardiographic reporting system should be integrated with the digital imaging system. With this integrated system, measured echocardiographic data are transferred automatically to the echocardiographic report and a still frame or even small clip of a real-time image can be included. The echocardiography report is the medium through which an echocardiographer conveys not only the descriptive ndings of echocardiography but, more importantly, the clinical implications and diagnostic considerations in the context of the patients clinical presentation. A report should do the following three things: 1) answer referral questions; even if echocardiography does not demonstrate any abnormality to explain the patients symptoms, the absence of positive ndings should be stated; 2) describe unsuspected, but clinically important, ndings; and 3) provide basic data for all patients. The basic data include the following: left ventricular systolic and diastolic function, left ventricular cavity size, wall thickness, right ventricular size and function, valvular structure and function, left atrial volume, anatomy of the great vessels, and pulmonary artery