C&apfer 3

Basic Principles of

M-Mode Echocardiography

Isolated motion-mode (M-mode) echocardiography was fir'st used in the early 1960's in the examinatior.r of cardiac structures and cardiac pathology. With the advent of realtirne, two-dimensional (2-D) imaging and Doppier-derived haemodynamic data, the role of M-mode as the pritlary diagnostic tool in the ecl,ocardiographic examination has diminished considerably. Despite this. M-mode rcmains

Basic PrinciPles of [Vl-Mode

M-mode echocardiography produces one-dimensional infbrt'nation on a time-motion graph' Infbrmation is
displayed along a line representing the ultrasound beam direction. By sweeping this single line of information across the display, a graph of the motion of intracardiac structures transected by the beam, with respect to time' can be achieved (Figure 3.1)' Therefore, the M-mode trace records the depth and motion of echocs arising frorn

tundar.nental part

ol the routine

echocardiographic

exarnination.

Figure 3.1: The Basic Principles of M-Mode. is depicted transecting the heart through the left ventricular This schematic illustrates a cross-section of the heart. The M-mode cursor ultrasound through the aorla and left atrium (3). Motion of the structures transected by the cavily (1),ihrough the mitral valve (2), and of information across the image display' line beam can be displayed throughout the cardiac cycle by sweeping this single mitral valve leaflet; IVS = interventricular septum; LA = left atrium;

Abbreviations: Ao = aorta; AoV = aortic valve; amvi= anterioi

1-y=leftventricle;pmvl=posteriormitralvalveleaflet;PW=posteriorwall;RV=rightventricle;S=sternum'

intracardiac strllctures relative to time. Three types of information can be obtained from the M-modc exarnination: (1) motion or time whicli is displaycd on the horizontal axis, (2) distancc or depth rvhich is displayed on the vefiical axis, and (3)echo strength r,r'hich is represented as the brightness of structures appearing on the imagc display. This echo brightness is directly proportional to the strength ofthe reflected echoes so that blood-filled cavities produce no echoes and solid strLlctures such as cardiac valves and wa11s produce strong echoes.

and/or interventricular septum due to aortic regurgitation (Figure 3.2). Detection of subtle changes may also aid the semiquantitation of the severity of the lesion; for example. early closure olthe mitral valve and premature operring of the aofiic valve as seen in acute severe aortic regurgitation may only bc appreciated by M-mode. M-modc also provides excellcnt interface definition enhancing the accuracy of mcasurements of cardiac
chambers and great vessels. This accuracy has been

futher

The principal
measurement

application

echocardiographic examination

of M-mode in is in the assessment

the
ancl

of

cardiac chau,ber dimensions. valvular

motion and left ventricular systolic function. M-node echocardiography is also useful for the specific evaluation of
the timing ofevents occurring throughout the cardiac cyc1e. The optimum windorv selected for M-mode interrogation is the view in which the ultrasound beam passes perpendicular to the structure(s) olintcrest.

enhanced by utilising 2-D guidancc. 2-D imaging allou's the display ol spatial infomation, which assists precrse alignment of the M-mode cursor as well as allowin-e the identification of anatomical structures transected b1' the cursor.

Colour Doppler M-mode incorporates both colour flou Doppler imaging (CFI) and M-mode. Therefore, colour Doppler M-mode provides infbrmation about time. distance, velocity and direction. This technique can be employed in the assessment of diastolic function ol the
left ver.rtricle (discussed fur-ther in Chapter l5) and in the timing of cardiac events.

Advantages of M-Mode Kclroeardiography The principal advantage ol M-mode

echocardiography

over other echocardiographic modalities such as 2-D

imaging and Doppler methods is its superior temporal resolution. The sampling rate for M-mode is approximately 1000 to 2000 pulses per second, which is lar grcater than 2-D echo lrame rate of between 30 to 100 fi'ames per second. Therefore, M-mode provides valuable information regarding last moving stl-Lrctures sllch as cardiac valves. Fr.rrthennore, subtle changes in valvular or wall motion are also more readily appreciated with M-mode. Examples of the subtleties detected by M-rnodc include the hi-eh frequency vibrations produced by vegetations, early systolic closure of the aortic valve due to sub-aortic obstruction. and diastolic flutter

ol the n.ritral valve

The graphical display ol colour Doppler M-mode allows the rapid and careful evaluation of time-related events which may not be readily appreciated by 2-D and CFI alone. An example where colour M-mode is particularly helpful is the recognition of diastolic mitral regurgitation which is seen in certain conduction abnormalities such as cor.nplete hearl block as well as with acute, severe aorlic regurgitation (Figure 3.3). Colour Doppler M-mode can also be used in the assessment of aorlic regurgitation to measure thc height olan aortic regurgitant jet (Figure 3.4) and/or to detenline the presence ol pan-diastolic flow reversal in aortic regurgitation (Figure 3.5). It has also been suggested that colour Doppler M-mode may be valuable in the differentiation of constrictive pericarditis lrom restrictive cardiomyopathies. lql

Figure 3.3: Diastolic Mitral Regurgitation.

This is a colour M-mode example of diastolic mitral regurgitation (arrows) in a patient with first degree heart block. This trace was obtained from the apical four chamber view with the M-mode cursor transecting the mitral valve leaflets which are depicted by the white, linear echo in the centre of the M-mode trace. Observe the timing of the colour flow Doppler signal with the ECG. Mitral regurgitation (the mosaic jet under the mitral leaflets) begins in mid-diastole, well before the QRS complex of the ECG. M,mode is useful in this insiance as the precise timing of regurgitation may not be clear from the real-time colour flow Doppler image alone.

Figure 3.2: Diastolic Flutter of the Anterior Mitral Valve with Aortic Regurgitation. This is an M-mode example of diastolic flutter of the anterior mitral leaflet because of the aortic regurgitant jet slamming into this leaflet (arrows) Observe the fine, high frequency vibrations
displayed on this leaflet during diastole. The presence of diastolic flutter of the mitrai valve is often the first clue to the presence of aodic regurgitation.
9: Ra.jagopalanN,CarciaMJ,RodnguczL,etal'.Anrerit:cutJotn'nalof

Cunliologt,6T;86 9q,2001

Disadvantages of lVl-tVlode Echocardiograplry

-;

predominant limitation of M-mode is its lack of .;:.:::1 rnlomation and its one dimensional nature such

-:

.-.,: rnlr-the structure(s) transected by the M-mode cursor .1i.p1ayed. This lack of spatial orientation has since E j:- overcome with the advent of 2-D guidance of the '.1-:rlode cursor.

r-:;lisition of data from a single dimension also poses ; :-::ficant limitations in the derivation of information
.-'-Ll a three-dimensional structure. Whenthe 1eft ventricle a long (major) axis shaped ' -rniibrmly ratio of with the M-mode-derived to shorl 2:1, ejection :r:ror) axis

,:,i:ion is relatively reliable. However, in

nost

:.::rrlogical states such as coronary artery disease, the :rg a\is to short axis ratio is altered. In this instance,
-.: \f-rnode-derived ejection fraction is often misleading. - *rhennore, accuracy of M-mode measurements is also ::;endent on the recognition of clearly defined borders, r:,r,-h are often ambiguous.

Figure 3.5: Golour M-mode of Pan-diastolic Flow Reversal in the Descending Aorta.
This is a colour M-mode example demonstrating pan-diastolic flow reversal in the descending aorta. This trace was obtained from the suprasternal long axis view with the M-mode cursor transecting along the descending aofta. Observe that blue flow (flow away from the transducer) occurs during systole (normal flow). The red flow within the aortic lumen (flow towards the transducer) commences at the beginning of diastole and continues throughout diastole (abnormal pan-diastolic flow reversal). Pan-diastolic flow reversal is an indirect sign of significant aodic regurgitation (discussed further in Chapter 13). M-mode is useful in this instance as the duration of flow may not be evident on the real-time colour flow Doppler image.

ir.rther disadvantage of M-mode is that many of

'.I-ntode measurements used

the

assess left '" :itricularperformance are affected by many variables and :- e. therefore, unreliable. ln addition, many ofthe M-mode "sr_:ls" ol cardiac diseases such as those described lor

to indirectly

:;lmonary hyperlension, vegetations and aofiic valvular

;.:ease, are not specific or sensitive. Furlhermore, these .:_grs have since been superseded by more reliable and
:,-.-Llrate Doppler techniques.

References and Suggested Reading

(listed in alphabetical order): . De Mey S, Dc Suttcr J, Vierendeels J. Verdonck P. Diastolic filling and pr-essure imaging: taking advar,tagc of the inlonlation in a colour M-mode Dopplcr imagc. European Journal of Echocardiography 2:219-33,2001.

Due to these major limitations, the sole utilisation of \f-mode in the assessment and diagnosis ol these

:;thological

states is no longer employed, thus reducing potential for false negative and false positive results. .re

Rajagopalan N, Garcia MJ, Rodrigucz L, et al: Comparison of nelv Doppler eclrocardrographic n'rethods to differentiate constrictive pericardial hearl disease and restrictive cardiomyopathy. American Journdl ol Cardiolog.t, 87 86 94, 2001. Weynran AE (editor). Principle.s antl PrrLclice of Echocartliograph,,". Chapter 14. 2nd Ed. Lea & Febiger, 1994.

Figure 3.4: Golour M-mode of an Aortic Regurgitant Jet. This is a colour M-mode example of aortic regurgitation. This :race was obtained from the parasternal long axis of the left '.ientrice with the M-mode cursor transecting the left ventricular outflow tract (LVOT). Observe the mosaic aoftic regurgitant jet rvithin the LVOT during diastole. Measurement of the jet height and the LVOT height can be used in the semiquantification of ihe severity of aortic regurgitation (discussed further in Chapter 13). M-mode may be useful in thls case as the superior interface definition may improve measurement accuracy.