Echo Basic

7/27/2019 Echo Basic

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EE - views

e sequence of the following views is based on the position of the transesophageal echocardiography (TEE) probe in

phagus and/or stomach. The course of the examination depends on the specific clinical questions and will be

uenced by the patient tolerance. The views shown here should only serve as orientation, since anatomy and anato

ationships may differ from patient to patient, an on the other hand, omniplane transesophageal examination allow

sible views between 0 and 180.

Upper position - view of the great vessels, 0: the ascending aorta (Ao), the ma

pulmonary artery (MPA) and the right pulmonary artery (RPA) can be displaye

Upper position - view of the aortic valve and the pulmonary artery, 40-50: the aortic

(AV), the main pulmonary artery (MPA), the right ventricular outflow tract (RVOT) and

left atrium (LA) can be displayed.

Upper position - view of the aortic valve, 40-50: the aortic valve (AV), the left atrialappendage (LAA) and the left atrium (LA) can be displayed.


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Mid-position views, 0: the left (LV) and the right ventricle (RV), as well as the left (LA) and righ

atrium (RA) can be displayed. This view is similar to the four-chamber view in TTE. It is possible

a two-chamber view (60) and three-chamber view (120) from this position.

Mid-position views, 90 left: the left ventricle (LV), the left atrium (LA), the left atrial

appendage (LAA) and the left upper pulmonary vein (LUPV) can be displayed.

Mid-position views, 90 right: the left (LA) and right atrium (RA), as well as the right at

appendage (RAA), the superior vena cava (VCS), the right pulmonary artery (RPA), the

interatrial septum and the inferior vena cava (VCI) can be displayed.


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Mid-position views, 90 further right: the left atrium (LA), the right upper pulmonary v

(RUPV) and the right pulmonary artery (RPA) can be displayed.

Mid-position views, 120: the ascending aorta (Ao), the left atrium (LA), the left ventrioutflow tract (LVOT) and part of the right ventricular outflow tract (RVOT) can be disp

Transgastric view - short axis, 0: the left (LV) and the right ventricle (RV), as well as th

can be displayed.


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Transgastric view - long axis, 90: the left ventricle (LV) and the mitral valve apparatus

can be displayed.

Dorsal view - during pullback, 0: the descending aorta (AD) can be displayed.

Exit view, 0: last view before TEE probe pullback is completed. At the upper part of th

ascending aorta turn the probe to the right, to display the aortic arch (AB) completely


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ransthoracic examination

dard measurements][Normal values]

o-dimensional views

Parasternal long axis: place the transducer on the 3rd intercost

space left parasternal. The transducer's index mark is directe

towards the patient's right shoulder. The right (RV) and the left

ventricle (LV), as well as the aortic bulb (Ao) and the left atrium

can be displayed.

Parasternal short axis (papil- lary muscle level): turn the transd

90 clockwise from the previous position. The left ventricle (L

the level of the papil- lary muscles and the right ventricle (RV) c

displayed.

Parasternal short axis (mitral valve level): tilt transducer a little

the same position down to the right. A cross section of the left

ventricle (LV) at the level of the mitral valve and the right vent

(RV) can be displayed.
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Parasternal short axis (aortic valve level): tilt transducer a little

from the same position down to the right. The aortic valve (AV

pulmonary valve (PV), the left atrium (LA) and the right atrium

as well as the tricuspid valve (TV) and the right ventricular outftrack (RVOT) can be displayed.

Apical four-chamber view: place transducer on the 5th inter- c

space, aprox. left midclavi- cular. The transducer's index mark

directed towards the patient's left side. The left (LV) and the ri

ventricle (RV), as well as the left (LA) and the right atrium (RA)

displayed.

Apical two-chamber view: turn the transducer aprox. 60 coun

clockwise from the previous position. The left ventricle (LV) an

left atrium (LA) can be displayed.


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Apical three-chamber view: turn the transducer further, aprox

counter-clockwise from the previous position and side tilt sligh

The left ventricle (LV), the left atrium (LA) and the aortic bulb (

can be displayed.

Apical five-chamber view: show a four-chamber view and then

the transducer slightly down. The aortic valve (AV) can be seenmiddle, between chambers. Tilting the transducer to the oppo

direction, the coronary sinus can be displayed.

Subcostal view: place the transducer on the subxyphoid regiontransducer's index mark is directed towards the patient's head

inferior vena cava (VCI) can be displayed. Turn the transducer

clockwise slightly to diplay the right and left ventricle, as well a

right (RA) and left atrium.


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Suprasternal view: place the transducer on the suprasternal re

The transducer's index mark is directed towards the patient's h

and turned aprox. 45 to the right. The aortic arch (*), the neck

arteries (TB, CL, SL) and the right pulmonary artery (RPA) as wethe left atrium (LA) can be displayed.

[overview]

ndard measurements - parasternal view

(1) Aortic bulb

(2) Left atrium

(3) Interventricular septum

(4) LV-EDD (end diastolic

diameter, LV)

(5) Posterior wall

(6) LV-ESD (end systolic

diameter, LV)

asurements must always be done perpendicular to the main axis of a vessel, a chamber or atria. The aortic bulb should be measured at t

nning, the left atrium at the end of the ventricular systole. Perpendicular "cuts" from the parasternal view in adults are often not possib

rt axis can be taken instead for a better orientation. A global impression from all views is necessary in order to avoid under- or overestim

imensions.

refore, traditional measurements with M-Mode from parasternal can not be recommended anymore.

[overview]
http://www.echobasics.de/tte-en.html#tophttp://www.echobasics.de/tte-en.html#tophttp://www.echobasics.de/tte-en.html#tophttp://www.echobasics.de/tte-en.html#tophttp://www.echobasics.de/tte-en.html#tophttp://www.echobasics.de/tte-en.html#top


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mal values

Diameters

Aortic bulb < 40 mm

Asce aorta < 40 mm

Aortic arch < 30 mm

Descendinaorta < 20 mmLeft atrium < 40 mm

Right atrium < 35 mm

Right ventricle < 30 mm

Inferior vena cava < 20 mm

Interventricular septum 6-10 mm

Posterior wall 6-10 mm

Lelft ventricle - end diastolic 40-55 mm

Left ventricle - end systolic variable

Doppler velocities

Aortic valve 1.35 (1.0 - 1.7) m/s

Mitral valve 0.90 (0.6 - 1.3) m/s

Pulmonary valve 0.75 (0.6 - 0.9) m/s

Tricuspid valve 0.50 (0.3 - 0.7) m/s

American Society of Echocardiography has published new recommendations for chamber quantification. This document can be downloaded directly from the ASE:

mmendations for Chamber Quantification, 2005.

hetic valves - normal values

cities depend not only from the diameter and type of the prosthesis, but also from the degree of hyperdynamia (pregnant women, hyperthyoidism, anemia), significant pro

regurgitation, and the "too-small-to-fit" phenomenon, caused by too small prosthetic valves for the native anatomic architecture.

mal velocity (Vmax) in m/s, peak pressure gradient (PPG) and mean pressure gradient (MPG) in mmHg. AVP = prosthetic aortic valve, MVP = prosthetic mitral valve.
http://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdf


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tress echocardiography

utamine SE][Dipyridamole SE]

ocardiographic examinations under dynamic or pharmacological stress are conducted with strict, and continuous monitorin

umentation of systemic arterial pressures and ECG. Image documentation and archiving are carried out by means of digitalwares, which allow a posterior evaluation of the examination in quad screen format.

ndard protocols are used for the different stress modalities.

amic stress echocardiogram

rmacological stress echocardiogram: Dobutamine
http://www.echobasics.de/se-en.html#1http://www.echobasics.de/se-en.html#2http://www.echobasics.de/se-en.html#2http://www.echobasics.de/se-en.html#2http://www.echobasics.de/se-en.html#2http://www.echobasics.de/se-en.html#1


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rmacological stress echocardiogram: Dipyridamole


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ardiac asynchrony

different electromechanical delays are measured from QRS start to contraction start,but some times they will be measured

e-to-peak manner (QRS to maximal velocity), in cases of difficult TDI profiles.

ellent reviews on cardiac asynchrony (dyssynchrony) and resynchronisation therapy were published recently in theJournal o

erican Society of Echocardiography.

essment of RV and LV delays: (using TDI, RV-free wall, LV septal basal, LV lateral basal, LV posterior basal)

Intraventricular asynchrony: LVsep - LVlat or LVsept - LVpost > 55 ms

Interventricular asynchrony: RVfw - LVsep > 70 ms or RVfw - LVlat > 55ms

Summ of asynchrony: LVas + RVas > 100 ms

essment of PET: (pre-ejection time, PW-Doppler, RVOT and LVOT)

Intraventricular asynchrony: LVpet > 140 ms

Interventricular asynchrony: RVpet - LVpet > 40 ms

T optimization:

Definite echocardiographic parameters for DRT optimization are still not available. VTI assessment at the

level of the LVOT, right underneath the aortic valve e.g., can give hints to acute changes in left ventricular

function, that may happen during manipulations in AV- and/or LV-RV-Delays and help in the decision to

optimal CRT setting.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17218205&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17218205&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17218205&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17218205&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17218205&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17218205&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum


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train Strain rate

ain: myocardial deformation (strain) can be assessed with this tool. It can be obtained based on Tissue Doppler Imaging (TDI

mensional images (speckle tracking). TDI allows better time definition and can be also used in case of poor echocardiograph

dows. Analyses from bidimensional images allow assessment of radial and circumferencial strain, the latter needed to calcu

tricular torsion. Normal values of longitudinal LV deformation are between - 20 to - 25 %.

ain rate: rate of myocardial deformation in time. Units are expressed in number/second or %/second. Diastolic myocardial

ormation can be assessed more clearly in this way. Normal values of longitudinal LV deformation are 1 - 1.5/s or higher.

e an extensive tutorial on this topic byDr. Asbjrn Stylen - NTNU Trondheim, Norway.

Normal strain: values of myocardial deformation at systole lie here around - 25 %

lateral segments of the left ventricle. Color encoded dynamic bidimensional imag

to visualize strain, red stands here for - 20 %.

Pathological strain: values of myocardial deformation at systole lie here around - 7

being consequently very reduced. This case is a proven myocardial involvement in

systemic amyloidosis.
http://www.echobasics.de/long-en.htmlhttp://www.echobasics.de/long-en.htmlhttp://folk.ntnu.no/stoylen/strainrate/#introhttp://folk.ntnu.no/stoylen/strainrate/#introhttp://folk.ntnu.no/stoylen/strainrate/#introhttp://folk.ntnu.no/stoylen/strainrate/#introhttp://www.echobasics.de/long-en.html


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Normal strain rate: values of diastolic myocardial deformation in this normal heart

between 1.3 and 1.7/s.

Pathological strain rate: this former amyloidosis case shows also a severe impairmelongitudinal diastolic myocardial deformation, with values around 0.6/

ndications for

ocardiographic

mination

[Transesophageal examination][Stress echocardiography]

Transthoracic echocardiography is an examination with not known side effects, has a widespread availability,

represents a low-cost high-effective approach and can be used in a large variety of clinical questions. Howeve

if the possibility of becoming a wide range screening method exists, echocardiography examinations should b

rationalized to meet criteria of incremental clinical value.

The following lists of indications are based in recent publications regarding appropriateness and clinical applic

ofechocardiography, as well as appropriateness criteria forstress echocardiography. Indications displayed be

represent only class I indications, i.e. conditions for which there is evidence and/or general agreement that a

procedure is useful and effective. Newest publications classify these indications as grouped in score 7 to 9, i.e

appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indic

Only some indications grouped under score 9 are listed below. For extensive content please refer to: Douglas

al. J Am Coll Cardiol 2007;50:187204 and Douglas PS et al. Circulation 2008;117:1478-1497. These guidelines

provide an estimate of the reasonableness of the use of echocardiography in different settings. However, clin

udgment will still be playing the most important role in determining whether to order an specific imaging mo

for an individual patient.

NewAppropriate Use Criteria for Echocardiography(PDF) published ahead for 2011.
http://www.echobasics.de/indic-en.html#1http://www.echobasics.de/indic-en.html#2http://www.echobasics.de/indic-en.html#2http://www.echobasics.de/indic-en.html#2http://content.onlinejacc.org/cgi/reprint/50/2/187.pdfhttp://content.onlinejacc.org/cgi/reprint/50/2/187.pdfhttp://content.onlinejacc.org/cgi/reprint/50/2/187.pdfhttp://content.onlinejacc.org/cgi/reprint/j.jacc.2007.12.005v2http://content.onlinejacc.org/cgi/reprint/j.jacc.2007.12.005v2http://content.onlinejacc.org/cgi/reprint/j.jacc.2007.12.005v2http://www.asecho.org/files/EchoAUC.pdfhttp://www.asecho.org/files/EchoAUC.pdfhttp://www.asecho.org/files/EchoAUC.pdfhttp://www.asecho.org/files/EchoAUC.pdfhttp://content.onlinejacc.org/cgi/reprint/j.jacc.2007.12.005v2http://content.onlinejacc.org/cgi/reprint/50/2/187.pdfhttp://www.echobasics.de/indic-en.html#2http://www.echobasics.de/indic-en.html#1


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Indications for transthoracic examination (selected main indications)

Symptoms potentially due to suspected cardiac etiology.

Assessment of known or suspected adult congenital heart disease.

Evaluation of suspected complication of myocardial ischemia/infarction.

Initial evaluation of murmur in patients for whom there is a reasonable suspicion of valvular or structura

disease.

Initial evaluation of prosthetic valve for establishment of baseline after placement.

Initial evaluation of suspected infective endocarditis with positive blood cultures or a new murmur.

Evaluation of cardiac mass (suspected tumor or thrombus).

Evaluation of pericardial conditions: i.e. pericardial effusion, constrictive pericarditis.

Known or suspected Marfan disease for evaluation of proximal aortic root and/or mitral valve.

Initial evaluation of known or suspected cardiomyopathy.

Indications for transesophageal examination

Evaluation of suspected acute aortic pathology including dissection/transsection.

To determine mechanism of regurgitation and determine suitability of valve repai

To diagnose/manage endocarditis with a moderate or high pre-test probability (e

bacteremia, especially staph

bacteremia or fungemia).

Persistent fever in patient with intracardiac device.

Evaluation of patient with atrial fibrillation/flutter to facilitate clinical decision-ma

with regards to anticoagulation

and/or cardioversion and/or radiofrequency ablation.


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Indications for stress echocardiographic examination (some score 8 indications also included h

Initial evaluation of chest pain syndrome or anginal equivalent

Intermediate pre-test probability of CAD, ECG uninterpretable OR unable to exerc

Worsening symptoms: abnormal catheterization OR abnormal prior stress imaging stu

Re-evaluation of medically managed patients.

Chest pain syndrome or anginal equivalent, prior test result

Coronary artery stenosis of unclear significance (cardiac catheterization or CT

angiography).

Preoperative evaluation for noncardiac surgery, high-risk nonemergent surgery

Poor exercise tolerance (< 4 METs, < 75 Watts at bicycle exercise).

Risk assessment post-revascularization (PCI or CABG), symptomatic

Evaluation of chest pain syndrome, not in the early post-procedure period.

Ischemic cardiomyopathy, assessment of viability/ischemia

Known CAD on catheterization, patient eligible for revascularization.

Valvular stenosis

Evaluation of equivocal aortic stenosis, evidence of low cardiac output, use of

dobutamine.


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Use of contrast with stress echo

Selective use of contrast, 2 or more contiguous segments are NOT seen onnoncontrast images.

Training in echocardiography

The following section is short summary from the report:American College of Cardiology/American Heart Associatio

Clinical Competence Statement on Echocardiography, Quiones MA et al. Circulation 2003;107:1068-1089. For ext

depiction of cognitive and technical skills required for competence in TEE, stress echo, as well as documentat

and maintenance of competence in each of those examination modalities, please refer to this unique publicat

Basic requirements for competence in echocardiography

Knowledge of physical principles of echocardiographic image formation and blood flow velocity

measurements.

Knowledge of instrument settings required to obtain an optimal image.

Knowledge of normal cardiac anatomy.

Knowledge of pathologic changes in cardiac anatomy due to acquired and congenital heart disease.

Knowledge of fluid dynamics of normal blood flow.

Knowledge of pathological changes in blood flow due to acquired heart disease and congenital heart dis

Requierements for competence in adult transthoracic echocardiography

Basic knowledge outlined in above.

Knowledge of appropriate indications for echocardiography.

Knowledge of the differential diagnostic problem in each case and the echocardiographic techniques req

toinvestigate these possibilities.

Knowledge of appropriate transducer manipulation.

Knowledge of cardiac auscultation and electrocardiography for correlation with results of the echocardio

Ability to distinguish an adequate from an inadequate echocardiographic examination.
http://circ.ahajournals.org/cgi/reprint/107/7/1068http://circ.ahajournals.org/cgi/reprint/107/7/1068http://circ.ahajournals.org/cgi/reprint/107/7/1068http://circ.ahajournals.org/cgi/reprint/107/7/1068http://circ.ahajournals.org/cgi/reprint/107/7/1068http://circ.ahajournals.org/cgi/reprint/107/7/1068


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Knowledge of appropriate semi-quantitative and quantitative measurement techniques and ability to

distinguish

adequate from inadequate quantitation.

Ability to communicate results of the examination to the patient, medical record, and other physicians.

Knowledge of alternatives to echocardiography.

Training requirements for performance and interpretation of adult transthoracic echocardiography

ystolic LV function

onal wall motion][18 segment model][Examples]

essment and description of left ventricular function comprises usually its systolic or diastolic, global or regional aspects.

ocardial function during the whole cardiac cycle is more complex, due to myocardial architecture. Radial left ventricular func

dominates certainly, but longitudinal and torsional function also play a role. Global strain (e.g. 2D-strain), as well as other

ameters, can give an insight in the longitudinal left ventricular function. Radial LV function can be assessed with the method

sented below.

alitative assessment of systolic LV function

multiple cross-sectional views

endocardial movement and myocardial thinckening

Assessment: "descriptive" | Ejection fraction, %*

normal | 55 %mild impairment | 45 - 54 %

moderate impairment | 30 - 44 %

severe impairment | < 30 %

*Current reference limits after the new recommendations ofAmerican Society of Echocardiography

(ASE), 2005.
http://www.echobasics.de/systole-en.html#1http://www.echobasics.de/systole-en.html#2http://www.echobasics.de/systole-en.html#2http://www.echobasics.de/systole-en.html#3http://www.echobasics.de/systole-en.html#3http://www.echobasics.de/systole-en.html#3http://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.echobasics.de/systole-en.html#3http://www.echobasics.de/systole-en.html#2http://www.echobasics.de/systole-en.html#1


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antitative assessment of systolic LV function

Calculation of left ventricular ejection fraction, LV-EF

Formula: [(EDV - ESV) / EDV] x 100 = EF (%)

Assessment of LV volumina with the method of discs (modified Simpson's rule, biplane)

ional wall motion assessment

segment model: left ventricular wall segments

re are several models to depict left ventricular wall segments, and correspondingly, some confusion. The 16-segment mode

gested by the American Society of Echocardiography in 1989 has proven its practicability in clinical work. Three-chamber vie

d regularly in echocardiography examinations in Europe since decades introduced two more apical segments: anteroseptal a

posterior apical. In American models, apical segments remained only 4: apical anterior, apical lateral, apical inferior and ap

tal. A new model was recently proposed, in order to equalize standards in echocardiographic, thallium-scintigraphy, NMR an

minations. The document can be downloaded directly from the ASE:Recommendations for Chamber Quantification, 2005.
http://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdfhttp://www.asefiles.org/ChamberQuantification.pdf


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ical distribution of coronary perfusion and the new 17-segment model from the ASE shown here as an overlay to the old mo

Mouseover (enable JavaScript in your browser).

mples of wall motion abnormalities

t: normokinesia of all wall segments in four-chamber view. Notice the slight lesser movement of septal compared to lateral

ments. This is a physiological phenomenon.

ht: lateral hypokinesia. A light increase of wall thinkness during systole can still be seen. Notice the clear septal hyperdynam

mpensatory reaction.

t: inferior basal akynesia, inferior medial hypokinesia in the two-chamber view. Notice the absence of myocardial thickening

netic segment.

ht: dyskinesia of the LV apex. Notice die excentric movement of the corresponding LV segments during the systole.


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Diastolic LV function

tral annular velocities][Pulmonary veins][Vp][Parameters to assess diastolic LV function][Algorithm]

rerequisite to assessment of diastolic LV function is the capability of the method to measure pressures, and Doppler

ocardiography is only able to measure velocities. Only through application of formulas, as the modified Bernoulli equation (

it is possible to estimate pressure gradients.

erent alternative possibilities to assess diastolic LV function were developed in the last decades. However, these tools made

gnosis of global diastolic LV dysfunction not always easy and clear. Sometimes different parameters just do not match to eac

er, or can not be correctly interpreted in case of atrial fibrillation or flutter.

ew equation enables non-invasive assessment of PCWP, the Nagueh-Formula: 1,9 + (1,24 E/E') = PCWP, that could make

mation of diastolic function in some way easier, since PCPW mLAP LVEDP. Here anonline calculatorfrom the Canadian S

chocardiography, to calculate PCWP.

ssic parameters are still in current use and will be presented below. Currentguidelinesof the American Society ofocardiography concerning diastolic function can be found here.

ral inflow velocities examination

sed wave Doppler (PW-Doppler) allows the measurement of velocities at the level of the sample volume. Two flow

ocity envelopes can be seen during diastole in persons with sinus rhythm: the E-wave, representing the early, pass

ng of the left ventricle, and the A-wave, that happens late in diastole, representing the active filling, the atrial

traction.

Left: PW-Doppler sample volum

placed at the tips of the mitral

in the left ventricle.

Right: normal mitral velocities,

coming from the left atrium in

ventricle during diastole, show

with color Doppler.
http://www.echobasics.de/diastole-en.html#2http://www.echobasics.de/diastole-en.html#1http://www.echobasics.de/diastole-en.html#1http://www.echobasics.de/diastole-en.html#5http://www.echobasics.de/diastole-en.html#5http://www.echobasics.de/diastole-en.html#3http://www.echobasics.de/diastole-en.html#3http://www.echobasics.de/diastole-en.html#4http://www.echobasics.de/diastole-en.html#4http://www.echobasics.de/diastole-en.html#4http://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=pcwpnaguehhttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=pcwpnaguehhttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=pcwpnaguehhttp://www.asecho.org/files/DF.pdfhttp://www.asecho.org/files/DF.pdfhttp://www.asecho.org/files/DF.pdfhttp://www.asecho.org/files/DF.pdfhttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=pcwpnaguehhttp://www.echobasics.de/diastole-en.html#4http://www.echobasics.de/diastole-en.html#3http://www.echobasics.de/diastole-en.html#5http://www.echobasics.de/diastole-en.html#1http://www.echobasics.de/diastole-en.html#2


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Left: pulsed wave (PW)

Doppler spectral display

shows an E-wave with hi

velocities, as well as an e

diatolic A-wave with lowvelocities.

Right: an A-wave twice a

large as the E-wave indic

impaired LV relaxation.

[overview]

tral annular velocities examination

w wall velocities can be assessed with Tissue Doppler Imaging (TDI). The sample volume, when placed at the medial mitral a

ws slower velocities as when placed at the lateral annulus. The E/E' relationship will be different according to each case, ma

re difficult the interpretation of results.

Left: PW-TDI sample volume is

at the level of the lateral mitral

annulus.

Right: normal LV wall velocities

during cardiac cycle, here a colo

coded display.

Left: spectral tissue Doppler (TDI)

shows an antegrade systolic, and

retrograde waves, E' (passive LV fi

and A'-wave (atrial contraction).

Right: E' and A' waves show here a

reversed relationship. In com- bina

with other parameters this could i

an impairment of relaxation or a

pseudonormal pattern.
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[overview]

lmonary venous flow examination

monary venous flow velocities can be assessed with PW-Doppler. Localization of pulmonary veins with color Doppler is relat

y, and allows to place sample volume at the right position.

fulness of the examination of pulmonary venous for estimation of left atrial pressure was shown byKuecherer Het al. Circu

0;82:1127-1139.

Left: pulmonary venous flow ca

assessed with PW-Doppler from

apical four-chamber view.

Right: normal pulmonary veinvelocities into the left atrium d

cardiac cycle, here shown with

Doppler.

Left: PW Doppler spectral displ

shows a larger systolic (S), a dia

(D) and a smaller end- diastolic

(AR), the atrial contraction.

Right: the shift towards diastol

a predominant diastolic wave (

speak for an increase of LA pre

This can be documented in a ca

impairment of LV compliance

(restrictive pattern).

[overview]
http://www.echobasics.de/diastole-en.html#tophttp://www.echobasics.de/diastole-en.html#tophttp://www.ncbi.nlm.nih.gov/sites/entrez?term=Kuecherer%20HF%2C%20Muhiudeen%20IA%2C%20Kusumoto%20FM%2C%20Lee%20E%2C%20Moulinier%20LE%2C&query=Kuecherer%20HF%2C%20Muhiudeen%20IA%2C%20Kusumoto%20FM%2C%20Lee%20E%2C%20Moulinier%20LE%2C&sourceid=mozilla-search&cmd=search&db=pubmedhttp://www.ncbi.nlm.nih.gov/sites/entrez?term=Kuecherer%20HF%2C%20Muhiudeen%20IA%2C%20Kusumoto%20FM%2C%20Lee%20E%2C%20Moulinier%20LE%2C&query=Kuecherer%20HF%2C%20Muhiudeen%20IA%2C%20Kusumoto%20FM%2C%20Lee%20E%2C%20Moulinier%20LE%2C&sourceid=mozilla-search&cmd=search&db=pubmedhttp://www.ncbi.nlm.nih.gov/sites/entrez?term=Kuecherer%20HF%2C%20Muhiudeen%20IA%2C%20Kusumoto%20FM%2C%20Lee%20E%2C%20Moulinier%20LE%2C&query=Kuecherer%20HF%2C%20Muhiudeen%20IA%2C%20Kusumoto%20FM%2C%20Lee%20E%2C%20Moulinier%20LE%2C&sourceid=mozilla-search&cmd=search&db=pubmedhttp://www.echobasics.de/diastole-en.html#tophttp://www.echobasics.de/diastole-en.html#tophttp://www.echobasics.de/diastole-en.html#tophttp://www.ncbi.nlm.nih.gov/sites/entrez?term=Kuecherer%20HF%2C%20Muhiudeen%20IA%2C%20Kusumoto%20FM%2C%20Lee%20E%2C%20Moulinier%20LE%2C&query=Kuecherer%20HF%2C%20Muhiudeen%20IA%2C%20Kusumoto%20FM%2C%20Lee%20E%2C%20Moulinier%20LE%2C&sourceid=mozilla-search&cmd=search&db=pubmedhttp://www.echobasics.de/diastole-en.html#top


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locity of flow progression (Vp)

ocity of flow progression (Vp) during diastole can be assessed with color Doppler M-mode. A Vp > 50 cm/s can be considere

mal. A E/Vp 2.5 in a patient with impaired systolic left ventricular can predict a PCWP > 15 mmHg.

Left: a narrow color Doppler se

placed between mitral valve an

apex. The M-mode examinatio

is place through the center of t

entrance flow.

Right: here a normal case. The

Nyquist-limit should be reduce

spontaneous aliasing is ob- serv

The first aliasing velocity front s

be measured.

Left: higher velocities at the A-

can be seen at impairment of L

relaxation, even without chang

Nyquist-limit.

Right: here an example of a res

pattern. The Vp is 27 cm/s and

clearly under the limit of 45 cm

[overview]
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ocardiographic parameters to assess diastolic LV function

concept ofRosetta Stonefor diastole was presented first by Rick A. Nishimura und A. Jamil Tajik,J Am Coll Cardiol 1997;30:

very important to understand, that the diagnosis of diastolic LV dysfunction can not be made with one parameter alone.

atient with dyspnea, preserved systolic LV function, dilated left atrium and elevated pulmonary artery systolic pressure, with

significant mitral valve disease that could explain these findings, is the patient that requires an intensified search for diasto

function.

mpaired relaxation, II: moderate diastolic dysfunction (pseudonormal), III: restrictive left ventricular filling (impaired LV

mpliance), ECG: electrocardiogram, MI: mitral inflow, MA: mitral annular velocities, PVF: pulmonary venous flow, Vp: velocityw progression, LA: left atrium, PASP: pulmonary artery systolic pressure.

ery good dynamic presentation of diastolic LV dysfunction ca be found here:Dr. Guido Giordano - Catania, Italia.

[overview]
http://en.wikipedia.org/wiki/Rosetta_Stonehttp://en.wikipedia.org/wiki/Rosetta_Stonehttp://en.wikipedia.org/wiki/Rosetta_Stonehttp://www.ncbi.nlm.nih.gov/pubmed/9207615?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSumhttp://www.ncbi.nlm.nih.gov/pubmed/9207615?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSumhttp://www.ecocardiografia.info/didat_diast_en_II.htmhttp://www.ecocardiografia.info/didat_diast_en_II.htmhttp://www.ecocardiografia.info/didat_diast_en_II.htmhttp://www.echobasics.de/diastole-en.html#tophttp://www.echobasics.de/diastole-en.html#tophttp://www.echobasics.de/diastole-en.html#tophttp://www.ecocardiografia.info/didat_diast_en_II.htmhttp://www.ncbi.nlm.nih.gov/pubmed/9207615?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSumhttp://en.wikipedia.org/wiki/Rosetta_Stone


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orithm for practical assessment of diastolic LV function

HA: New York Heart Association classification to stages of heart failure, LV-EF: left ventricular ejection fraction, E/E': relation

ween maximal values of passive mitral inflow (E, PW-Doppler) and lateral early diastolic mitral annular velocities (E', TDI), LV

-diastolic LV pressure, PASP: pulmonary artery systolic pressure.

Longitudinal ventricular function

uantitative assessment][Torsional function]

onardo da Vinci described as early as 1478, that contracting hearts showed a movement from thethe apex during each cardiac systole. Ventricular torsion was first described by William Harvey in

cently, a new dissection technique developed byFrancisco Torrent Guaspand published in 1980,

ow the complexity of myocardial architecture, explaining all types of cardiac movement during the

art function.
http://www.echobasics.de/long-en.html#1http://www.echobasics.de/long-en.html#2http://www.echobasics.de/long-en.html#2http://www.echobasics.de/long-en.html#2http://www.torrent-guasp.com/PAGES/VMB%20Form.htmhttp://www.torrent-guasp.com/PAGES/VMB%20Form.htmhttp://www.torrent-guasp.com/PAGES/VMB%20Form.htmhttp://www.torrent-guasp.com/PAGES/VMB%20Form.htmhttp://www.echobasics.de/long-en.html#2http://www.echobasics.de/long-en.html#1


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e picture left shows a very simplified scheme of the helical ventricular myocardial band. To the rigperposition with the apical four-chamber view. (1) band insertion at the pulmonary artery, (2) free

ll, (3) basal loop, (4) apical loop and (5) insertion at the aorta.

om this architectonic structure of the heart can be perceived, that the right ventricle will have a

edominantly longitudinal and torsional, and the left ventricle a preponderant radial function.

antitative assessment of longitudinal venticular function

ngitudinal LV function can be quantitatively assessed with different methods. The degree of

ovement of the atrioventricular plane can be determined with M-mode, its velocity with tissue Do

aging (TDI). Longitudinal deformation examined withstrain/strain ratecan be also very helpful.

e following values reflect the lower normal limits of longitudinal LV and RV function:

MAPSE (mitral annular plane systolic excursion) 1 cm

MASV (mitral annular systolic velocity) 10 cm/s

LV-LSS (left venticular longitudinal systolic strain) 20 %
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TAPSE (tricuspid annular plane systolic excursion) 2 cm

TASV (tricuspid annular systolic velocity) 20 cm/s

RV-LSS (right ventricular longitudinal systolic strain) 30 %

tained values can be influenced by at least 4 factors: age, angulation of examination beam (M-mo

I), respiration and method-dependent (PW-TDI versus color TDI, the latter shows significant lowe

ues). Studies that define normal values in larger populations are still lacking.

Left: MAPSE is assessed with M-mode in apic

four-chamber view, placing the examination

on the lateral mitral annulus.

Right: measurement take place from the end

diastole, until maximal expansion in systole.

Left: pulsed TDI sample volume is placed on

lateral mitral annulus to assess systolic veloc

Possible oscillation due to respiration, as we

MAPSE, should also be avoided here.

Right: here an example of TDI velocities of m

annulus, with a important wave of isovolum

contraction. This wave should not be taken f

systolic wave.

rsional ventricular function

sional ventricular LV function can be calculated with the formula: LVtor (degree/cm) = (apical LV rotation basal LV

ation)/longitudinal diastolic LV dimension. Normal value = 3/cm; it shows no variation with age (Kim HK et al. J Am Soc

ocardiogr 2007;20:45-53).


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Left: a counterclockwise rotation of the apex

clockwise rotation of the base can be determ

in normal physiology.

Right: assessment of ventricular rotation is neasy, especially at the ventricular base. It ca

conducted with B-mode strain, as in this exa

V function

rameters][Algorithm][3D volumetry]

e assessment of the right ventricle (RV) is in a continuos state of "work in progress". Parameters, values and algori

sented here may be interpreted differently in the future.

e to complex RV morphology, a quantitative assessment of systolic RV function is not possible with established

thods, since a required cylindrical form is not available. Therefore, systolic RV function is assessed only qualitative

ional or global RV dilatation must be documented, as well as the diameter and respiratory behavior of the inferio

a.

not known if available parameters to assess diastolic LV function would have the same value when assessing dias

function. However, other have found its place, e.g. parameters for assessment of global function (Tei-index) or

gitudinal systolic function (TAPSE, TASV, RV-strain). A review can be found atAdvances in Pulmonary Hypertensio

tGuidelines for the Echocardiographic Assessment of the Right Heart in Adults(PDF) published in 2010.

ameters for quantitative assessment: TAPSE, TASV, Tei-Index, Lei

owing values can provide support in the diagnosis of a right ventricular dysfunction:

TAPSE (tricuspid annular plane systolic excursion) < 2 cm

TASV (tricuspid annular systolic velocity) < 20 cm/s

Tei-Index (myocardial performance index) > 0,50

Lei (LV eccentricity index) > 1
http://www.echobasics.de/rv-en.html#1http://www.echobasics.de/rv-en.html#2http://www.echobasics.de/rv-en.html#2http://www.echobasics.de/rv-en.html#3http://www.echobasics.de/rv-en.html#3http://www.echobasics.de/rv-en.html#3http://www.phaonlineuniv.org/Journal/Vol5No3Autumn06/OptimizingEchocardiographyhttp://www.phaonlineuniv.org/Journal/Vol5No3Autumn06/OptimizingEchocardiographyhttp://www.asecho.org/files/rhfinal.pdfhttp://www.asecho.org/files/rhfinal.pdfhttp://www.asecho.org/files/rhfinal.pdfhttp://www.asecho.org/files/rhfinal.pdfhttp://www.phaonlineuniv.org/Journal/Vol5No3Autumn06/OptimizingEchocardiographyhttp://www.echobasics.de/rv-en.html#3http://www.echobasics.de/rv-en.html#2http://www.echobasics.de/rv-en.html#1


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The assessment of RV function starts with the

measurement of RV dimentions and the quali

evaluation of its function.

Left: the right ventricle appears normal in size

systolic function. Notice the smaller RV surfac

compared to the LV (aprox. 1:2 to 1:3).

Right: massive dilated RV with severely reduc

systolic function.

Left: TAPSE can be assessed with M-mode,

measuring the distance of tricuspid annularmovement between end-diastole to end- syst

Right: the velocity of this movement can be

measured with TDI.

Left: color encoded tissue Doppler imaging (T

Right: Tei-index, also known as "myocardial

performance index" (MPI) can be assessed wi

Doppler in RVOT and RV inflow, and also with

with the formula (a-b)/b.


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Left: ventricular interdependence can be clea

recognize here. The LV is impaired in its funct

through a significant septal inden- tation.

Right: eccentricity index (Lei), systolic and diais an important parameter that can be deter

with the formula: Lei = D1/D2. Normal value =

gorithm for assessment of RV function

s propositionfor estimation of right ventricular function begins with the assessment of RV morphology. It is very important t

mine and document the RV from all its 9 different echocardiographic views. Be careful: the RV appears larger than normal wmined too medially, or projections with apical foreshortening.

er aspects that must be taken into account when assessing RV function are: physiology of the inferior vena cava, pulmonary

ssures, severe tricuspid regurgitation, impaired left ventricular function, suspicion of atrial shunt.
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sessment of RV function with 3D-echo

function can accurately be assessed with three-dimensional echocardiography. Requirements are: a matrix-array

rasound probe and a current software for offline analysis of 3D data.

re some examples of examinations with 2D and 3D echocardiography.

breviations: EDV, end-diastolic volumen; ESV, end-systolic volumen; EF, ejection fraction.

Left: dilated RV with 3D volumetry, here

from the front. Red represents the apex, g

the inflow and yellow the outflow track.

Right: the same RV, here seen from behin

Grey surfaces represent tricuspid and


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pulmonary valves.

Left: here the 2D examination of the samefrom the apical four-chamber view. Qualit

assessment show a severe impairment of

function.

Right: here the quantitative results of 3D

volumetry.

Left: the RV only mildly dilated and its funis slightly impaired, here seen from the f

Right: same case seen from behind.

Left: 2D examination of the same case, fro

apica four-chamber view. Qualitative

assessment show a mildly impaired RV fun

Right: quantitative results of 3D volumetr

confirm the qualitative estimation of RV

function.

Assessment of pulmonary artery pressure (PA-pressure)

e systolic PA-pressure (PASP) is an indicator of cardiac hemodynamic status and can be quiet


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curately non-invasively assessed with echocardiography. There are several pitfalls that may produ

er- and underestimation.

e PASP at rest is also an independent predictor of prognosis and an indicator for elevated left

ntricular filling pressures [Lam CS et al. 2009]. During exercise, and already at low stages (throughatt), it can raise over 40 mmHg in 10 % of healthy persons under the age of 60 years. In 30 % of he

mily members with genetic predisposition to pulmonary arterial hypertension (I/FPAH), it can also

er 40 mmHg at the same conditions [Grnig E et al. 2009].

lowing animations show pathophysiological aspects of PA-pressure behavior.

essment of PA-pressure is an important part of a correctly and comprehensive conducted echocardiographic examination.

essment of pulmonary artery systolic pressure (PASP) can be carried out by measuring maximal tricuspid regurgitation veloc

applying the modified Bernoulli equation to convert this value into pressure values. Estimated right atrial pressure (RAP) m

ed to this obtained value. Mean (PAMP) and diastolic PA-pressures (PADP) can be estimated by assessment of the pulmona

urgitation.

Systolic PA-pressure (PASP)

PASP = tricuspid regurgitation gradient + RA

pressure (RAP)

PASP = (Vmax x 4) + RAP

Normal values: rest up to 30 mmHg, duringexercise up to 40 mmHg.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2753443/?tool=pubmedhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2753443/?tool=pubmedhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2753443/?tool=pubmedhttp://circ.ahajournals.org/cgi/content/full/119/13/1747http://circ.ahajournals.org/cgi/content/full/119/13/1747http://circ.ahajournals.org/cgi/content/full/119/13/1747http://circ.ahajournals.org/cgi/content/full/119/13/1747http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2753443/?tool=pubmed


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Mean PA-pressure (PAMP)

PAMP = pulmonary regurgitation gradient (M

Normal values: rest up to 25 mmHg, during

exercise up to 30 mmHg.

Diastolic PA-pressure (PADP)

PADP = pulmonary regurgitation gradient (D

RAP

Left: estimated RA-pressure is up to 5 mmHg

when inferior vena cava collapses complete

inspiration.

Right: estimated RA-pressure can be 10, 20,

mmHg in case of absence of inferior vena ca

collapse or presence of a severe tricuspid

regurgitation. Tricuspid velocities are slower

case, comparison to PAMP can be helpful.

Valvular heart disease

tral valve stenosis][Valvular regurgitation]

e EAE/ASE have published new recommendations for the evaluation of valvular stenosis. The document (PDF) can

wnloaded directly from the ASE:Echocardiographic assessment of valve stenosis, 2009.

rtic valve stenosis

ACC/AHA 1998 guidelines for grading an aortic valve stenosis
http://www.echobasics.de/klappen-en.html#1http://www.echobasics.de/klappen-en.html#2http://www.echobasics.de/klappen-en.html#2http://www.echobasics.de/klappen-en.html#2http://www.asecho.org/files/VSGuideline.pdfhttp://www.asecho.org/files/VSGuideline.pdfhttp://www.asecho.org/files/VSGuideline.pdfhttp://www.asecho.org/files/VSGuideline.pdfhttp://www.echobasics.de/klappen-en.html#2http://www.echobasics.de/klappen-en.html#1


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* information not available (Bonow et al. Circulation 1998;98:1949-1984)

PPG = peak pressure gradient, MPG = mean pressure gradient

Continuity equation: standard method to calculate valvular opening area. Systolic velocities in left ventricular outf

rack (LVOT) and on the aortic valve, as well as LVOT area must be assessed.

= aortic stenosis area, V2 = aortic stenosis velocity time integral (VTI, obtained with CW-Doppler), A1 = LVOT area

= LVOT VTI (obtained with PW-Doppler).

culation of the continuity equation can be usually made in every echomachine, but in case this is not possible, hie

ine calculatorof the Canadian Society of Echocardiography.

Left: assessment of valvular morphology ist the first step to a c

diagnosis of valvular heart disease. Here a cross sectional view

aortic valve from the parasternal short axis view.

Right: the aortic valve is thickened, calcified and with severely

leaflet separa- tion, as seen from the apical five-chamber view
http://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=avavtihttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=avavtihttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=avavti


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Left: color Doppler helps to CW-Doppler beam

positioning. Pin hole stenoses are very difficu

examine, fact that can lead to important

underestimation of velocities.

Right: maximal velocities from 4.5 m/s or abo(peak pressure gradient aprox. 80 mmHg) can

considered as a thumb rule for severe aortic

stenosis.

[overview]

tral valve stenosis

rect assessment of the pressure half time (PHT) is decisive for calculating mitral valvular opening area, correspondingly its st

ree. This can be difficult in case of atrial fibrillation, since Doppler profile inclination varies with the duration of diastole.

Left: a dilated left atrium is a common occurre

a significant mitral stenosis.

Right: the degree of thickness, calcification an

movement limitation of the whole mitral valv

apparatus are important parameters for dec

to a percutaneous valvuloplasty (Wilkins-Scor

ne calculatorfrom the Canadian Society of

Echocardiography).
http://www.echobasics.de/klappen-en.html#tophttp://www.echobasics.de/klappen-en.html#tophttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=mvsmghhttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=mvsmghhttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=mvsmghhttp://www.echobasics.de/klappen-en.html#top


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Left: a concurrent mitral valve regurgitation m

included in the evaluation before valvulo- pla

Right: different values of PHT can be obtained

case of atrial fibrillation, according to diastole

length. It is importante to find a mean value, t

correlate to measured values of transmitral

gradients.

lvular regurgitation

Overview

valvular regurgitations have three components: PISA (proximal isovelocity surface area), vena contracta and regurgitation je

be spontaneously seen when regurgitation is already significant. Vena contracta plays a more important role for assessmen

ree of regurgitation than regurgitation jet.

ena contracta with an area larger than 50 % of LVOT, with a regurgitation jet deceleration >3 m/s and a diastolic retrograde

he descendant aorta can be consistent with the diagnosis of a severe aortic regurgitation.


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ide vena contracta with a v-shaped regurgitation jet (CW-Doppler), PISA and systolic retrograde flow into the pulmonary ve

consistent with the diagnosis of a severe mitral regurgitation. A TEE examination to exclude e.g. partial ruptured chordae

dineae can be necessary in this case, especially in presence of an eccentric mitral regurgitation.

etrograde flow into the hepatic veins together with the afore mentioned parameters lead to the diagnosis of a severe tricusp

urgitation.

arameters for quantitative assessment: EROA, regurgitation volumen, regurgitation fraction

w "high-end" echomachines simplify the assessment of the effective regurgitation orifice area (EROA), regurgitation volume

tion.

essment of EROA can be carried out with the continuity equation, where A1 (PISA area), V1 (PISA Nyquist-limit) and V2

gurgitation VTI) are the known variables, and A2 (EROA) the variable to be calculated.

OA = (PISA area x PISA Nyquist-limit) / regurgitation VTI

urgitation volume = SVreg - SVnorm

SVreg: Stroke volume measured at the regurgitating valve

SVnorm: Stroke volume measured at a valve without regurgitation

urgitation fraction = Regurgitation volume / SVreg

SV (Stroke volume) = CSA (cross sectional area, valve annulus) x VTI

ortic valve regurgitation

Mitral valve regurgitation


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culations with the PISA method can usually be made directly in the echomachine, alternatively here anonline calc

m the Canadian Society of Echocardiography. Excentric regurgitations may produce inaccurate results.

omplete description of all criteria for the assessment of valvular regurgitation can be downloaded from the Ameri

iety of Echocardiography:Recommendations for Evaluation of the Severity of Native Valvular Regurgitation, 2003

Left: color Doppler settings must be correctly

adjusted for the PISA method. The Nyquist-limshould be placed around 50-60 cm/s.

Right: afterwards, base line should be shifted

direction of the regurgitation jet, until a well-

defined hemisphere appears.

Left: to calculate VTI of regurgitation jet, CW

Doppler profile area should be delineated.

Right: by measuring PISA radius it is importan

correctly the limit ot the hemisphere. Small e

can produce important variations.

Left: furthermore, it is very important to def

cause of the valvular regurgitation. Here a TEexamination of partial ruptured chordae tend

of the posterior mitral leaflet.

Right: a severe, excentric mitral regurgitation

verified with color Doppler.
http://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=pisamrhttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=pisamrhttp://www.asefiles.org/vavularregurg.pdfhttp://www.asefiles.org/vavularregurg.pdfhttp://www.asefiles.org/vavularregurg.pdfhttp://www.csecho.ca/cardiomath/?eqnHD=echo&eqnDisp=pisamr


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ntracardiac masses

mors][Other intracardiac masses]

rombio examples of thrombi in the left atrial appendix (LAA) seen at a TEE examination.

t: this thrombus has a wide attachment in the LAA, but also an extreme mobile part, that prolapses in part as far as the mitr

ve.

ht: large wall-adherent thrombus in LAA.

o examples of thrombi in the left atrium at the TEE examination.

t: a large, in part wall-adherent thrombus at the LA roof can be seen in a severe mitral stenosis case.

ht: a large free-floating thrombus bounces at irregular intervals against a mitral valve prosthesis.

o other examples of thrombi in the LA.

t: the TEE examination of a thrombosed mitral prosthesis shows a large wall-adherent LA thrombus that reaches to the pros

ht: mitral stenosis TTE examination. A large mobile thrombus in LA mimics an atrial mymoma.

o examples of LV thrombi at the TTE examination.

t: wall-adherent thrombus in LV apex aneurysm.

ht: wall-adherent, echolucent thrombus in LV apex in a dilatative cardiomyopathy.

o further examples of thrombi in the LV apex at the TTE examination.

t: wall-adherent thrombus, but with a narrow attachment.

ht: here a similar case. Echolu- cent aspect and myxoma-like movement speak for a relative recently formed thrombus.

[overview]

mors
http://www.echobasics.de/mass-en.html#1http://www.echobasics.de/mass-en.html#2http://www.echobasics.de/mass-en.html#2http://www.echobasics.de/mass-en.html#2http://www.echobasics.de/mass-en.html#tophttp://www.echobasics.de/mass-en.html#tophttp://www.echobasics.de/mass-en.html#tophttp://www.echobasics.de/mass-en.html#2http://www.echobasics.de/mass-en.html#1


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o examples of LA myxomas at the TEE examination.

t: large characteristic left atrial myxoma with attachment at the atrial septum. The myxoma prolapses in the LV through the

ve during diastole.

ht: mid-size, round myxoma with attachment in the superior portion of the atrial septum.

o further examples of masses at the TTE examination.

t: large metastasis of a renal cell carcinoma in the RV.

ht: large mediastinal mass at the level of the great vessels.

her intracardiac masseso examples of valvular vege- tations at the TEE examination.

t: large vegetation attached to a bioprosthesis in aortic position.

ht: large vegetation on a native mitral valve.

t: large round vegetation on a native tricuspid valve at the TEE examination.

ht: Chiari network in RA at the TTE examination. Notice a hyper- mobile atrial septum and the clear ultrasound shade due to

nular calcificacion.

t: pronounced spontaneous echo contrast in LAA at the TEE examination.

ht: cardiac involvement of hypereosinophilic syndrome. Well defined masses fill completely the apical regions of both ventr

Pericardial disease

nstrictive pericarditis]

ricardial effusion

cardial effusion estimation is usually done cualitatively. Measurements of systolic and diastolic dimensions from parasterna
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de is important, in order to allow follow-up controls. Hemodynamic severity can be assessed through evidence of atrial or

tricular wall compression, interventricular septum displacement during inspiration and inferior vena cava plethora with blun

piratory response.

Left: small pericardial effusion with inferior basal localization.

Right: small pericardial effusion with posterior basal localization.

Left: circular, mid-size pericardial effusion, with posterior und lateral accentuation.

Right: mid-size pericardial effusion, as well as large pleural effusion clear delimitated

through parietal pericardial line.

Left: mid-size to large pericardial effusion with important hemodynamic severity, asevidenced through RV compression.

Right: large, circular pericardial effusion. RV and LV filling show respiratory dependen

compromise.

Left: this same case from the parasternal short axis. Aspirated volumen was 1.5 liters

Right: inferior vena cava is plethoric and without respiratory collapse, a sign of

hemodynamic severity.

strictive pericarditis

Following images show characteristics of pericardial compression.

Left: contraction of the free RV wall is impeded through the organized pericardial effu

RV expands during filling at the beginning of each inspiration, only through a septal sh

toward the LV (septal bounce).

Right: E-wave shows a clear (> 25 %) increase in inspiration (1).


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Left: tricuspid regurgitation is also more evident during inspiration, here more accent

as in physiologic status.

Right: tricuspid regurgitation maximal velocity becomes lower as EROA increases.

Left: inferior vena cava is plethoric and show no inspiratory collapse.

Right: antegrade velocities in suprahepatic vein also show clear respiratory accentuac

Cadiomyopathies

t: dilatative cardiomyopathy (DCM) form the parasternal long axis view. The LV and LA are dilated.

ht: same case from the short axis view. Systolic LV function is severely reduced.

t: dilated cardiomyopathy with severly reduced systolic LV function as seen from the four- chamber view.

ht: here a DCM with severe mitral regurgitation.

t: a severe myocadial hypertrophy can point to a hypertrophic cardiomyopathy, but also as in this case, to a myoc

olvement by amyloidosis.

ht: hypertrophic nonobstruc- tive cardiomyopathy (HNCM) with normal systolic LV function. Atrial arrhythmia ma

ficult the interpretation of diastolic function.


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t: apical form of a hypertrophic cardiomyopathy.

ht: lung-crossing ultrasound contrast agent in a case of isolated left ventricular noncompaction cardiomyopathy

NC). Notice deep trabeculations in LV, especially the apical region.

Aortic dissection

ssification of aortic dissection

ndford A

t: dissection membrane starts approx. 2 cm above the aortic valve, the ascendant aorta is aneurysmatic.

ht: view of the ascendant aorta, so far it can be seen in the TEE examination. The left main bronchus hinders usually visuali-

ntersection of ascendant aorta to the aortic arch.

t: cross-section of the ascendant aorta in the same case. Notice the intramural hematoma previous to start of dissection

mbrane.

ht: further away of the aortic valve, intramural hematoma and start of dissection membrane.


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ndford B

ft: descendant aorta short after intersection from the aortic arch. Flat, wall-adherent plaques.

ght: same case, further distal from in the descendant aorta, a large intramural hematoma can be s

ft: more distal, a dissection membrane with entrance tear can be seen. False lumen at the bottom

e image.

ght: dissection membrane with entrance tear and color Doppler flow display.

ft: dissection membrane with entrance tear and PW-Doppler flow display.

ght: further distal in the descendant aorta, pronounced spontaneous echo contrast in false lum

Congenital heart disease

mplex congenital heart disease][More examples of congenital heart disease]

eratrial shunt Cross section of the right atrium as seen from the right side. At the top the superior ve

cava (VCS), at the bottom the inferior vena cava (VCI), to the right the tricuspid valve (T

1: Patent foramen ovale

2: ASD II = ostium secundum atrial septal defect

3: ASD I = ostium primum atrial septal defect

4: Sinus venosus defect

5: Anomalous drainage of one or more pulmonary veins

6: Sinus coronarius defect

An interatrial shunt may be suspected in the presence of following findings in transtho

echocardiography (TTE): dilated right ventricle with preserved systolic function, dilated

atrium, as well as increased velocities over the pulmonary valve.

To define localisation and morphology, as well as depiction of the shunt, a multiplane

transesophageal echocardiography (TEE) should be performed.

Non-invasive assessment of shunt magnitude (Qp:Qs) can be made with the following

formula: (CSARVOT x VTIRVOT)/(CSALVOT x VTILVOT). Cross sectional area (CSA) calculated fro
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diameter of the right (RVOT) and left ventricular outflow tract (LVOT) with B-mode and

velocity time integral (VTI) with PW-Doppler at the same place during passive end expi

Next 4 animations apply to an ostium secundu

atrial septal defect (ASD II).

Left: TEE examination at 0 shows a large ASD

the upper part of the fossa ovalis.

Right: ASD II at 90.

Left: demonstration of a large left-to-right shu

with color Doppler.

Right: negative contrast effect showed with a

transpul- monary ultrasound contrast agent, w

partial crossing from RA to LA.

Next 7 animations apply to ano- ther ASD II ca

Left: Four chamber view. The RV is dilated wit

severely decreased systolic function. The RA i

severely dilated. An atrial shunt is suspected.

examination should follow.

Right: short axis view shows a dilated RV.

Left: TEE view at 100 shows an ASD II at the

superior portion of the foramen ovale.

Right: Shunt depiction with color Doppler. The

Nyquist limit lies at 60-70 cm/s, slow velocitie

speak for a moderate to severe shunt.


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Left: ASD II depiction with "real- time 3D

echocardiography" (RT3D-TEE).

Right: The ASD II as seen from the LA (arrow),

superior vena cava (VCS) confluence and right

appendage (RAA) are labeled here.

Left: ASD II as seen from the right atrium (RA)

Depiction with RT3D-TEE uses colors to give t

impression of deepness: light blue lies on a de

level than light brown.

Right: Shunt depiction with color 3D

echocardiography, as seen from the RA.

Next 4 animations apply to different cases o

patent foramen ovale (PFO) and/or atrial sept

aneurysm (ASA).

Left: several small left-to-right shunts depicte

color Doppler (PFO fenestrations).

Right: ASA and PFO with massive right-to-left

ultrasound contrast agent passage at the end

Valsalva maneuver.

Left: spontaneous right-to-left shunt can be

depicted with color Doppler in cases of large P

Right: this can cause a reduction in oxygen

saturation and dyspnea during changes in bodposition (platypnea-orthodeoxia).

Left: here a case of a complete atrioventricula

canal defect, with ASD I and a large superior lo

VSD. Septal insertion of AV valves (mitral and

tricuspid) lies at the same level.


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Right: a malformation of the AV valves, espec

the mitral valve (cleft) cannot be seen in this c

[overview]

mplex congenital heart disease

Approach to echocardiographic diagnosis

1. Anatomic orientation

- Situs solitus

- Situs inversus

- Dextrocardia

- Dextroposition

2. Atrioventricular relationship

- Concordant

- Discordant

3. Great vessels

- 2 or 1

- Parallel course

- Ventricular-arterial concordance or discordance

4. Shunts

- Atrial

- Ventricular

- Great vessels: aortopulmonic window, Ductus arteriosus
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5. Valves

- Pulmonic stenosis

- Tetracuspid valve (truncus arteriosus)

- Aortic stenosis: valvular, subvalvular

- Bicuspid aortic valve/aortic isthmus stenosis

- Ebstein's anomaly

tensive and excellent Flash-animations from congenital heart disease can be seen at t

ealth Center Encyclopediafrom the Cincinnati Children's Hospital Medical Center.

Next 4 animations apply to a D-

transposition of the great vesse

(D-TGA).

Left: parallel course of the greavessels. The aorta lies ventral a

the pulmonary artery dorsal.

Right: short axis of the aortic

(above) and pulmonary valve

(below).

Left: four-chamber view, there

atrioventricular concordance.

However, the RV is the systemic

ventricle. Mustard baffle can be

seen right below at the RA.
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Right: pulmonary vein flow can

seen in and at the intersection o

the Mustard baffle to the RA.

Next 4 animations apply to a

Fallot's tetralogy.

Left: 50 to 60 % riding aorta and

large outlet VSD as seen from th

parasternal long axis.

Right: pulmonary stenosis as se

from the parasternal short axis.

Left: apical five-chamber view o

the riding aorta and the VSD.

Right: RV hypertrophy can be

clearly seen from the four-cham

ber view.

Next 4 animations apply to a

truncus arteriosus.

Left: from the parasternal long

view it looks like a Fallot's tetra

Right: VSD shunt can be seen w

color Doppler.


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Left: the truncus can be followe

a modified parasternal view.

Pulmonary artery originates do

from the truncus (below in the

image), approx. 4 cm distal to t

truncus valve.

Right: truncus valve is in this ca

bicuspid, and not tetracuspid as

expected.

re examples of congenital heart disease

Next 4 animations apply to an univentricu

heart.

Left: four-chamber view, a rudimentary RV

a large VSD can be seen.

Right: examination with an ultrasound

contrast agent. Anatomic and rheologic

characteristics of a double inlet LV (DILV),

without transposition of the great vessels

ventricular inversion.

Left: modified parasternal long axis view.

Right: with an ultrasound contrast agent c

seen, that blood flow from the caval veins

the rudimentary RV and the LV.


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Next 4 animations apply to an aortopulmonic

window.

Left: parasternal long axis view.

Right: severe RV and LV hypertrophy can be

from the short axis view.

Left: short axis view of the aortic and pulmon

valves shows a severe pulmonary artery dilata

Right: a modified view above this level shows

approx. 2 cm large window between aorta an

pulmonary artery.

Ductus arteriosus Botalli apertus.

Left: retrograde flow in the pulmonary art

seen with color Doppler.

Right: typical, systolic-diastolic flow with h

velocities as depicted with CW-Doppler.

Membranous subvalvular aortic stenosis.

Left: subvalvular membrane can be clearly

in five-chamber view.

Right: turbulence with color Doppler show

stenotic effect of the membrane.


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echo|case

o|case is an echocardiographic "showcase", intended to present pregnant, visual impressive echocardiographic

dings with high didactical value, seen from the point of view and experience of different echocardiographists. This

ection for case reports, namely, it is not destined for unusual echocardiographic cases or cases of excepcional

urrence.

obile left atrial mass

9-year-old male patient with a history of systemic arterial hypertension and type 2 diabetes, both under therapy,

mes to the outpatient clinic with dyspnea on effort, which was getting worse in the last two weeks.

e electrocardiogram showed sinus rhythm with frequent supraventricular extrasystolia, heart rate was 75/min, sig

ventricular hypertrohpy were present. Transthoracic echocardiography showed a hypertrophic left ventricle, dila

h an impairment of systolic function. Calculated ejection fraction is 40%.

omplementary finding complicated non-invasive diagnosis in this patient.

Left: B-mode, parasternal long axis projection. The left ventric

hypertrophic, with impareid contractility.

Right: an echogenic, mobile mass with inhomogeneous densi

be seen in the dilated left atrium, dimensions 25 x 20 x 30 mm

(arrow), with insertion on the interauricular septum.


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Left: apical four-chamber view, here inverted following a May

Clinic tradition. The mobile mass in the left atrium causes a pa

mitral valve obstruction during diastole.

Right: echocardiographic diagnosis suggest an ischemic card

myopathy with a concomitant left atrial myxoma.

ifferential diagnosis can be proposed: mobile thrombus in the left atrium. However, sinus rhythm make this optio

re distant. The diagnosis of atrial myxoma was histologically confirmed after surgery.

Echo Basic

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Transcript of Echo Basic