Echo Interpretation · Tricuspid Stenosis Mean pressure gradient (mm Hg) ≥ 5. Mitral Inflow...
Transcript of Echo Interpretation · Tricuspid Stenosis Mean pressure gradient (mm Hg) ≥ 5. Mitral Inflow...
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Echo InterpretationJason R. Morrissette, MSHS, MBA-HCM, PA-C
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Echo Machine
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Transthoracic Echocardiography Windows
• Left parasternal• Long axis view
• Short axis view
• Apical window• 4 chamber view
• 5 chamber view
• 3 chamber view
• 2 chamber view
• Subcostal/Subxiphoid window• Interatrial septum
• IVC
• Suprasternal window
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Parasternal Window, Long Axis
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Parasternal Window, Short Axis
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Parasternal window, short axis
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Apical window, 4 Chamber
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Apical window, 5 Chamber
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Apical window, 2 Chamber Apical window, 3 Chamber
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Subxiphoid View
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Suprasternal View
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Chamber Evaluation
• Left ventricle size and function
• Left ventricle wall thickness
• Left atrium dimensions
• Right ventricular size and shape
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Left Ventricle Size
• Measure in parasternal long axis, at the tip of the mitral leaflets
• Diastolic diameter: End diastole, frame after mitral closure; largest cardiac dimension
• Systolic diameter: End systole, frame preceding mitral valve opening; smallest cardiac dimension
• Exclude chordae and papillary muscle from measurement
• Measure perpendicularly to long axis of LV
• LV apex should not be visualized
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Left Ventricle Size
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Diastolic Diameter of LV
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Systolic Diameter of LV
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M-Mode of LV
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Left Ventricular Thickness
• Measure in parasternal long axis at end-diastole
• Exclude chordae and papillary muscle
• Exclude moderate bands from right ventricle
NormalMildly
abnormalModerately abnormal
Severely abnormal
LV Thickness (cm) 0.6 - 0.9 1.0 - 1.2 1.3 - 1.5 ≥1.6
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Left Ventricular Thickness
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Left Atrial Size
• Measured at end systole where LA chamber is at its greatest dimension
• Parasternal long axis, perpendicularly to the LA walls, leading edge to leading edge
Women MenAP Dimension (cm) 2.7 - 3.8 3.0 - 4.0
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Left Atrial Size
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Left Atrial Size - Volume
4 Chamber 2 Chamber
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Right Ventricle Size
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Right Ventricle Size
Normal Mildly abnormalModerately abnormal
Severely abnormal
RV ED Diameter (cm) 2.7 - 3.3 3.4 - 3.7 3.8 - 4.1 ≥4.2
Normal: RV < LV
Mildly enlarged: RV < LV
Moderately enlarged: RV = LV
Severely enlarged: RV > LV
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Right Ventricle Shape• Normal: Crescent
• Pressure/Volume overload: End-diastolic pressure of RV exceeds LV causing flatness of septum and inward bowing of LV during end-diastole and then in systole
RV
LV
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IVC assessment
• Subcostal 4 chamber view
• Visualize IVC merging with right atrium
• Measure 2-3 cm before merging with RA, parallel walls
• M mode across IVC
IVC Abdominal Aorta
Direction Goes through liver Goes through liver
Relationship to heart Merges with RA Continues down the heart
Flow Continuous Pulsatile
Walls Not visible Hyperechoic
Respiratory variation Yes No
Collateral vessels Hepatic veins merge with IVC Not visible at this level
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IVC and Aorta
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IVC and Aorta
IVC Aorta
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Left Ventricular Segmentation
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Ejection Fraction
•Normal 52 – 72%
•Mildly reduced 41 - 51%
•Moderately reduced 30 – 40%
• Severely reduced < 30%
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EF – Normal (52-72%)
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EF-Mildly Reduced (41-51%)
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EF-Moderately Reduced (30-40%)
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EF-Severely Reduced (<30%)
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Regional Wall Motion Abnormalities
• Septal hypokinesis
• Inferior and inferolateral hypokinesis
• Left and Right Ventricle dysfunction
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Septal hypokinesis
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Inferior and inferolateral hypokinesis
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Left and Right Ventricle Dysfunction
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Pericardial Effusion
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Pericardial Effusion
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Tamponade
• Early signs• IVC dilated, not collapsing • Increased respiratory variation in
mitral (> 25%) and tricuspid (> 40%) inflows
• Late signs• RA/RV collapse
• Very late signs• LA/LV collapse
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Valve pathology
• Mitral regurgitation
• Mitral stenosis
• Aortic insufficiency
• Aortic stenosis
• Tricuspid regurgitation
• Tricuspid stenosis
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Mitral Regurgitation
Jet area–Color Flow• Simple, quick screen for mild or severe central MR;
evaluates spatial orientation of jet
• Subject to technical, hemodynamic variation; significantly underestimates severity in wall-impinging (eccentric) jets
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Mitral Regurgitation
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Mitral Regurgitation: Torn MV Chord
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Mitral Stenosis
Mild Moderate Severe
Valve Area (cm2) > 1.5 1.0 - 1.5 < 1.0
Mean gradient (mmHg) < 5 5.0 - 10 > 10
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Aortic Insufficiency
Jet width in LVOT–Color Flow• Mild• Moderate • Severe
Jet deceleration rate – Pressure ½ time (msec)• Mild severity: > 500 • Moderate severity: 500-200 • Severe severity < 200
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Aortic Insufficiency
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Aortic Insufficiency – Pressure ½ time
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Aortic Stenosis
• (LVOT) velocity: measured from the apical approach either in an apical long-axis view or an anteriorly angulated four-chamber view
• Left ventricular outflow tract (LVOT) diameter- measured in the parasternal long-axis view in mid-systole
• Aortic valve jet velocity
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Aortic Stenosis: Grading Severity
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Aortic Stenosis
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Aortic Stenosis: Pre surg
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Aortic Stenosis: Post surg
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Systolic anterior motion (SAM) of MV
•Apposition of the tip of the mitral leaflet and septum in mid to late systole
• Subaortic obstruction in hypertrophic cardiomyopathy
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SAM
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SAM
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Tricuspid Regurgitation
Jet area–Color flow
• Simple, quick screen for TR
• Underestimates severity in eccentric jets
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Pulmonary Artery Pressure
• MPAP systole = 4 * (TR jet velocity)2 + Right Atrial Pressure (RAP)
RAP IVC diameter IVC collapsibility
3 mmHg < 21 mm >50%
8 mmHg < 21 mm <50%
10 mmHg > 21 mm >50%
15 mmHg > 21 mm <50%
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Tricuspid Stenosis
Mean pressure gradient (mm Hg) ≥ 5
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Mitral Inflow patterns
• Flow from Left Atrium to Left Ventricle occurs in 3 phases:
• E wave: Initial rush of blood into LV as MV opens in early diastole
• Diastasis: Period of low or no flow
• A wave: Atrial contraction results in final rush of blood into LV in end-diastole
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Mitral inflow, diastolic dysfunction
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Diastolic dysfunction
Normal Severe dysfunction
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Myxoma
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Right Atrial Mass
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Bubble Study
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Bubble Study - PFO
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Left Ventricle Apical Thrombus
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American Society of Echocardiography
• http://asecho.org