Echo Factsheets - 2nd Ed - 3
Echo Factsheets - 2nd Ed - 3
Echo Factsheets - 2nd Ed - 3
Factsheets
Companion Syllabus to the
Masterclass Lectures
This is not a textbook, it doesn’t even provide echo images. It‘s simply a
learning aid for everyone who wants to browse through the essentials of
echocardiography and make the facts stick.
Instead of using too much text or a dull checklist format, we put the echo
facts and graphics into tables and decorated them with images that will
help you remember the facts. Do some of these images look familiar?
Well, we also used them in our Masterclass presentations. After all, we
want to help you to remember what you have learned there. :-)
The positive feedback we got so far inspired us to make this book even
more practical. We threw out what was too much and added what we
think is essential. The result is this 2nd edition.
We hope this booklet will make a difference when you learn echocardio-
graphy and will improve your echo learning experience.
123sonography.com
CONTENTS
10 Physics of Ultrasound
11 2D Images
13 Artefacts
15 Optimizing 2D Images
15 MMode
16 Spectral Doppler
17 Flow Dynamics
18 Color Doppler
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
Medical Ultrasound
SEND RECEIVE
The higher the US frequency, the higher the pulse repetition frequency.
10
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
2D IMAGE NOTES
Image Quality
Gain Gray
11
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
NOTES 2D IMAGE
Limitations of 2D Imaging
Attenuation
Enemies of Ultrasound
Air (reflection of ultrasound) and bone (absorption of ultrasound)
In both conditions you cannot see what is behind.
12
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
ARTEFACTS NOTES
REVERBERATION –
apical four-chamber view/2D
Specific Forms
Side
Main lobe lobe
Side lobes usually occur at strong Reverberation occurs when the echo
reflectors (e.g. prosthetic material). Power bounces back and forth several times
density is higher in the central beam than – sometimes between a structure and
in side lobes. This may lead to the edge the surface of the transducer.
effect, which makes structures appear
wider than they actually are.
US beam
13
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
NOTES ARTEFACTS
GAIN SETTINGS – PSAX/2D
14
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
MMODE
15
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
NOTES MMODE
SPECTRAL DOPPLER
Doppler
Pulsed wave (PW) – Doppler Low velocity (< approx. 1.5 m/s) (site specific)
Continous wave (CW) – Doppler High velocity (> approx. 1.5 m/s) (site unspecific)
16
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
FLOW DYNAMICS
Bernoulli Equation
The simplified Bernoulli equation permits
easy estimation of pressure gradients P(mmHg)
from velocities.
V(m/s) P = 4xV2
P(mmHg)
17
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
COLOR DOPPLER
towards + 62 m/s
away - 62 m/s
18
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
19
001 // PRINCIPLES OF ECHOCARDIOGRAPHY
NOTES
20
002 // How to Image
CONTENTS
22 How to Move the Transducer
22 Imaging Windows
22 Image View
28 Abbreviations
21
002 // HOW TO IMAGE
Use enough
ultrasound gel.
IMAGING WINDOWS
Suprasternal
Use as many views as Parasternal 2nd–4th intercostal space R L
IMAGE VIEW
RV
AV
Ao
LV
MV
AMVL
LA
Parasternal
long-axis view
RV
Anterior
Posterior TV
Right
parasternal long axis
22
002 // HOW TO IMAGE
RV
RA RC
AC
LC
PA
LA
l-PA
r-PA
Parasternal short
axis – base
PM
PMPM AL
PM
23
002 // HOW TO IMAGE
Four-chamber view
Three-chamber view
Two-chamber view
24
002 // HOW TO IMAGE
RV LVOT
Ao
RA LA
RV LV
RA CS
RL – PV
LL – PV
RU – PV
LA LU – PV
Subcostal Views
Abdominal gas may
Subcostal four-chamber view obscure the apex on
the subcostal view.
LIVER
RV
RA LV
LA
In some patients it
Inferior vena cava view (rotate counterclockwise) may be possible to see
the superior vena cava
on this view.
LIVER
IVC
RV
RA
LA
SVC
25
002 // HOW TO IMAGE
RV
RA
Ao PA
ry
ry
te
te
ar
ar
The suprasternal view allows Suprasternal View
tid
ry
lic
te
ro
ha
ar
ca
you to detect coarctation, a
ep
an
on
oc
persistent Botalli‘s duct, or vi
m
a
hi
cl
m
ac
b
co
aortic dissection, as well as su
Br
ft
t
ef
Le
quantify retrograde flow in L
the aorta (aortic
regurgitation). r-PA
Asc Ao
Desc Ao
Suprasternal view
26
002 // HOW TO IMAGE
27
002 // HOW TO IMAGE
NOTES ABBREVIATIONS
AC = acoronary cusp
AL = anterolateral papillary muscle
Ao = aorta
Asc Ao = ascending aorta
AV= aortic valve
MV = mitral valve
PA = Pulmonary artery
PM= posteriomedial papillary muscle
RC = right-coronary cusp
RL-PV= right lower pulmonary vein
r-PA = right pulmonary artery
RU - PV= right upper pulmonary vein
RV= right ventricle
TV = tricuspid valve
28
003 // Heart Chambers and Walls
CONTENTS
30 The Left Ventricle
IVS RV
Moderate (mm) 64 – 68 58 – 61
Normal chamber size LVED Diameter/Body Surface Area (BSA) – Reference Values
increases with body
surface area
(and body size). Normal (cm/m2) 2.2 – 3.1 2.4 – 3.2
30
003 // HEART CHAMBERS AND WALLS
LV Systolic Volume (4-chamber view) – Reference Values Do not trace the papillary
muscles. Their volumes
should be included in the
Normal (mL) 22 – 58 19 – 49 calculation.
Mild (mL) 59 – 70 50 – 59
Moderate (mL) 71 – 82 60 – 69
Pathophysiology A reduction of
longitudinal function is an
Principles of LV Function: early marker of LV
Factors influencing ejection fraction/stroke volume dysfunction.
myocardial mechanics
stroke volume
31
003 // HEART CHAMBERS AND WALLS
32
003 // HEART CHAMBERS AND WALLS
33
003 // HEART CHAMBERS AND WALLS
CW Sample
DP/DT – apical four-chamber
view/CW Doppler mitral
regurgitation
MR
The dP/dt is calculated by
measuring the slope of the initial
mitral regurgitation signal
between 1 m/s and 3 m/s.
1 m/s
dP/dt
3 m/s
IVC
34
003 // HEART CHAMBERS AND WALLS
ESC/ASE 2005
Basal
35
003 // HEART CHAMBERS AND WALLS
TDI
SAMPLE RA
E‘ A‘
36
003 // HEART CHAMBERS AND WALLS
Mild (mm) 41 – 46 39 – 42
Moderate (mm) 47 – 52 43 – 46
Severe (mm) ≥ 52 ≥ 47
LA diameter/
BSA (mm/m2) 15–23 24–26 27–29 ≥ 30
LA diameter/
BSA (mm/m2) 15–23 24–26 27–29 ≥ 32
ESC/ASE 2005
37
003 // HEART CHAMBERS AND WALLS
Normal (mm) ≤ 50
Mild (mm) 51 – 60
Moderate (mm) 61 – 70 LA
Pulmonary vein
Normal (cm2) ≤ 20
Mild (cm2) 20 – 30
Moderate (cm2) 30 – 40
LA
ESC/ASE 2005
LA diameter
Pulmonary vein
38
003 // HEART CHAMBERS AND WALLS
Mild (mL) 59 – 68 53 – 62 50 – 70
Moderate (mL) 69 – 78 63 – 72 70 – 90
39
003 // HEART CHAMBERS AND WALLS
ESC/ASE 2005
Vena cava
40
003 // HEART CHAMBERS AND WALLS
Coronary Sinus
Concentric Concentric
remodelling hypertrophy
0.43
Normal Eccentric
hypertrophy
LVMI
41
003 // HEART CHAMBERS AND WALLS
Severe (mm) ≥ 17 ≥ 16
INTERVENTRICULAR
SEPTUM – apical four-chamber
view/2D
Interventricular septum
The interventricular septum is a
prominent structure. The center
of the septum is highly echoge IVS diameter
nic. A septal bulge is frequently
observed, especially in hyper-
tensive patients. The thickness
of the bulge should be reported
separately.
Buldge
42
003 // HEART CHAMBERS AND WALLS
43
003 // HEART CHAMBERS AND WALLS
NOTES
44
004 // Diastolic Function
CONTENTS
46 Basics of Diastolic Dysfunction
51 Specific Situations
45
004 // DIASTOLIC FUNCTION
IVRT Diastasis
46
004 // DIASTOLIC FUNCTION
EAE/ASE 2009
47
004 // DIASTOLIC FUNCTION
Lateral e‘ (cm/s) 20.6 ± 3.8 19.8 ± 2.9 16.1 ± 2.3 12.9 ± 3.5
EAE/ASE 2009
a´
e´
AR
48
004 // DIASTOLIC FUNCTION
AR (cm/s) 16 ± 10 21 ± 8 23 ± 3 25 ± 9
EAE/ASE 2009
Increasing filling pressures are seen in the patterns from left to right. Provocation
maneuvers such as Valsalva that unload the left atrium may cause a reversal of the
pattern (pseudonormal -> impaired relaxation and restrictive -> pseudonormal)
IMPAIRED RELAXATION
PATTERN – apical four-chamber
view/PW Doppler MV
E-wave
49
004 // DIASTOLIC FUNCTION
Mitral E/A
E/e’
E/e’ sep. ≥ 15 or
E/e’< 8
E/e’ 9 – 14 E/e’ lat. ≥ 12 or
(sep., lat. or av.)
E/e’ av. ≥ 13 or
50
004 // DIASTOLIC FUNCTION
SPECIFIC SITUATIONS
E/A Fusion
• Tachycardia
• Long systole (left bundle branch block)
• Long AV delay
51
004 // DIASTOLIC FUNCTION
L-wave
52
005 // Dilated Cardiomyopathy
CONTENTS
54 Background
54 Echo Features
55 Specific Forms
53
005 // DILATED CARDIOMYOPATHY
NOTES BACKGROUND
Associated Problems
ECHO FEATURES
54
005 // DILATED CARDIOMYOPATHY
Enlarged LA
SPECIFIC FORMS
55
005 // DILATED CARDIOMYOPATHY
TAKOTSUBO
CARDIOMYOPATHY – apical
four-chamber view/2D
Peripartum Cardiomyopathy
56
005 // DILATED CARDIOMYOPATHY
HIV-Mediated Cardiomyopathy
• Focal myocarditis
• Most common form of cardiomyopathy in African countries (e.g. Burkina Faso)
Causes
• Myocarditis • Nutritional deficiency
• Autoimmune cardiomyopathy • Drug toxicity (e.g. zidovudine)
LV NON-COMPACTION –
Sinus apical four-chamber view/2D
57
005 // DILATED CARDIOMYOPATHY
Echo Evaluation
• The involved segments are mid • Use color Doppler with low PRF and
ventricular (especially inferior and contrast to visualize blood flow
lateral) and apical. Is usually seen best between the trabeculae
on atypical views • Use deformation imaging to detect
• Right ventricular involvement may be myocardial dysfunction (i.e. speck-
present but is difficult to differentiate le-tracking echocardiography) at the
from normal trabeculae regions of hypertrabeculation
Chagas Disease
Echo Features
• Pericardial effusion
• Regional myocardial dysfunction
with preserved global left ventricular function
• Often apical aneuryms
• Diastolic dysfunction is present
in about 20% of patients
58
006 //
Hypertrophic Cardiomyopathy
CONTENTS
60 Basics
61 Echocardiographic Evaluation
59
006 // HYPERTROPHIC CARDIOMYOPATHY
NOTES BASICS
Symptoms
• Asymptomatic • Arrhythmias
• Chest pain • Sudden death
• ECG abnormalities • Dyspnea
• Syncope • Palpitations
OBSTRUCTIVE HYPERTROPHIC
CARDIOMYOPATHY –apical
four-chamber view/Color
Doppler Mid-ventricular
turbulences
Turbulent flow in the LVOT
caused by systolic anterior mo-
tion of the MV. Distortion of the
MV leads to regurgitation with
a posteriorly directed jet. Flow
PMVL
acceleration is also present in the
Posterior Turbulent flow LVOT
mid-ventricular portion (addi-
tional mid-ventricular obstruc-
MR jet
tion).
60
006 // HYPERTROPHIC CARDIOMYOPATHY
BASICS NOTES
ECHOCARDIOGRAPHIC EVALUATION
APICAL HYPERTROPHIC
Spade sign CARDIOMYOPATHY – apical
four-chamber view/2D
Apical
hypertrophy Pronounced hypertrophy of
the apex with a spade-shaped
ventricular cavity. Atrial enlarge-
ment is also a common feature of
hypertrophic cardiomyopathy.
61
006 // HYPERTROPHIC CARDIOMYOPATHY
SAM
LVO
T
AV
AM
VL
PMVL
Vmax
62
006 // HYPERTROPHIC CARDIOMYOPATHY
63
006 // HYPERTROPHIC CARDIOMYOPATHY
ESC 2003
64
007 //
Restrictive Cardiomyopathy
CONTENTS
66 Basics
67 Specific Forms
65
007 // RESTRICTIVE CARDIOMYOPATHY
NOTES BASICS
66
007 // RESTRICTIVE CARDIOMYOPATHY
Segmental
SARCOIDOSIS – apical
hypertrophy four-chamber view/2D
Wall Motion
abnormality Abnormal cardiac geometry with
Fibrosis segmental wall motion abnormal-
ities, thickening, and increased
echogenicity in the region of the
mid- and distal anterior septum.
Enlarged
atria
67
007 // RESTRICTIVE CARDIOMYOPATHY
Speckled
myocardaum
68
008 // Coronary Artery Disease
CONTENTS
70 Segmental Approach
77 Complications
69
008 // CORONARY ARTERY DISEASE
Mid ventricle
Base
Subdivision of the corresponding short-axis view (SAX). Note that the basal and mid SAX
consist of 6 segments while the apical SAX has only 4 segments (16-segment model).
Definition of the individual segments on the apical views. Note that the inferior
portion of the basal septum is visible on the 4-chamber view.
as al ai aa al/pl as
(a/i)ms ml mi ma mpl
m(a)s
(i)bs bl bpl
bi ba
b(a)s
70
008 // CORONARY ARTERY DISEASE
Inf Inf
71
008 // CORONARY ARTERY DISEASE
Left atrial
Mitral appendage
Coronary valve
sinus
72
008 // CORONARY ARTERY DISEASE
Normal
Exercise-
induced
ischemia
Ischemia
Necrosis
”Hibernation”
”Stunning”
73
008 // CORONARY ARTERY DISEASE
The degree of wall motion Myocardial Tissue After Acute Coronary Syndrome
abnormalities depends on
the transmurality of the
infarction. Various different
wall motion abnormalities
may exist simultaneously
(akinesia, hypokinesia,
aneurysm, scars).
Transmural scar: akinesia, dyskinesia, Subendocardial scar: hypokinesia,
aneurysm, thinning, bright echo thickness is normal/mildly thinned
Look for edema (myocardial
thickening, bright echoes) in
patients with myocardial
infarction after reperfusion.
74
008 // CORONARY ARTERY DISEASE
Region Solution
75
008 // CORONARY ARTERY DISEASE
Patients with left main Proximal LAD Type Infarction Small Basal Inferior
myocardial infarction rarely Infarction
survive.
LAD (before 1st septal branch, left main), Difficult region to interpret, low remode-
always remodeling, poor prognosis RCA ling risk
76
008 // CORONARY ARTERY DISEASE
CX, RCA, moderate remodeling risk Dominant RCA, CX (large, prox.), high
remodeling risk
COMPLICATIONS
77
008 // CORONARY ARTERY DISEASE
NOTES COMPLICATIONS
Myocardial Rupture
78
008 // CORONARY ARTERY DISEASE
COMPLICATIONS NOTES
ṔM head
VL
AM
PMVL
79
008 // CORONARY ARTERY DISEASE
NOTES COMPLICATIONS
APICAL THROMBUS – zoomed
apical four-chamber view/2D
80
009// Aortic Stenosis
CONTENTS
82 Basics
88 Special Circumstances
NOTES BASICS
PERCENT SURVIVAL
75
Without aortic
valve
50 replacement
Heart failure
25 Syncope
Angina
10 20 30
YEARS
Adapted from Ross Circulation 1968
Epidemiology
LV pressure overload
LVF
Heart failure
82
009 // AORTIC STENOSIS
BASICS NOTES
3%
23%
18%
50% 48%
25% 27%
83
009 // AORTIC STENOSIS
NOTES BASICS
2D
• Valve morphology (cusps) • Atrial enlargement
• Visual assessment of aortic valve • Exclude subvalvular membrane
opening and motion • Left ventricular hypertrophy
• Degree of calcification • Measurement of the aortic annulus (for
• Left ventricular function valve sizing in TAVR)
Cusp
84
009 // AORTIC STENOSIS
BASICS NOTES
Peak velocity
85
009 // AORTIC STENOSIS
A2 x V2 Ao
A1 x V1
LV
LA
LVOT diam = A1
A2 = V1 x A1 /V2
LV=Tvel = V1
AVvel = V2
86
009 // AORTIC STENOSIS
Aortic valve area > 1.5 cm2 1.0–1.5 cm2 < 1.0 cm2
ESC 2012
87
009 // AORTIC STENOSIS
The gradients
overestimate AS severity Aortic Stenosis and Aortic Regurgitation
only when aortic
regurgitation is moderate • Tend to occur simultaneously
or in excess of moderate. • Common in bicuspid valves
• Significant aortic regurgitation leads to higher
gradients (overestimation of the severity of aortic stenosis)
88
009 // AORTIC STENOSIS
SUBVALVULAR AORTIC
STENOSIS – PLAX/2D
AMVL
Echo Features
• Color flow aliasing at the site of • Membrane of varying thickness within
obstruction the LVOT, often with a small muscular
• Elevated CW velocity despite normal ridge. Best visualized on atypical PLAX
AV morphology views
89
009 // AORTIC STENOSIS
When the patient does not Indications for Surgery in Severe AS (Class I/ESC 2012)
fulfill the criteria/indications for
surgery, annual follow-up • Symptomatic patients with severe AS • When other cardiac surgery
should be performed. Shorter (dyspnea, syncope, angina) is being performed (e.g. CABG;
intervals are necessary when AS • Symptomatic patients with severe AS ascending aorta)
is severe, heavily calcified or and reduced LV function (<50% EF)
when symptoms are uncertain. • Asymptomatic patients with severe AS
and abnormal exercise test
90
009 // AORTIC STENOSIS
Transcatheter Aortic Valve Replacement (TAVR) The indications for TAVR may
change with improvements in
Consider interventional valve replacement in: methodology.
• Symptomatic/severe aortic stenosis
• High-risk patients
• Suitable anatomy (AV annulus diameter)
• Appropriate anatomical access for valve implantation (transfemoral/transapical)
Steel Frame
Bovine Valve
91
009 // AORTIC STENOSIS
NOTES
92
010 // Aortic Regurgitation
CONTENTS
94 Basics
NOTES BASICS
94
010 // AORTIC REGURGITATION
BASICS NOTES
Left carotid artery RETROGRADE FLOW IN AR –
suprasternal view/Color Doppler
Left subclavian artery
Aortic arch Severe retrograde flow during
diastole. The red color Doppler
signal denotes flow towards the
transducer from the descending
Retrograde flow
aorta towards the the arch. Color
Doppler may be used to guide
Pulmonary positioning of the PW Doppler
artery spectrum.
Forward flow
95
010 // AORTIC REGURGITATION
NOTES BASICS
VENA CONTRACTA –
apical three-chamber view
Flow
AMVL convergence
96
010 // AORTIC REGURGITATION
HEMODYNAMIC CALCULATION OF
REGURGITANT VOLUME AND FRACTION NOTES
SV LVOT – SV MV AR vol
RF (%) = = Hemodynamic calculations of
SV LVOT SV LVOT AR are rarely used. Their main
limitation is the inaccuracy of
SVMV = CSAMV x VTIMV SVLVOT = CSALVOT x VTILVOT calculating the MV cross-
sectional area.
CSA= d x 0.785
2
PROXIMAL ISOVELOCITY
SURFACE AREA (PISA) METHOD
Reference Values
ESC 2013
97
010 // AORTIC REGURGITATION
Surgery is indicated
98
011 // Mitral Stenosis
CONTENTS
100 Introduction
102 Quantification
104 Valvuloplasty
99
011 // MITRAL STENOSIS
NOTES INTRODUCTION
Doppler Features
• Color Doppler is indicative of mitral • CW Doppler is used to quantify mitral
stenosis (candle flame appearance) stenosis (gradients/pressure half-time)
100
011 // MITRAL STENOSIS
INTRODUCTION NOTES
DIASTOLE MITRAL STENOSIS – PLAX/2D
Shadow
Thrombus
101
011 // MITRAL STENOSIS
NOTES QUANTIFICATION
LA LA
102
011 // MITRAL STENOSIS
QUANTIFICATION NOTES
Moderate (mmHg) 5 – 10
220
MV Area = The pressure half-time method is
PHT based on hemodynamic
The rate at which the gradient between the left atrium and the left ventricle assumptions and was initially
diminishes corresponds to the size of the mitral valve orifice. The smaller the tested in young patients with
orifice, the longer is the pressure half-time. rheumatic heart disease. It
works less well in elderly and
multimorbid patients with
PHT – pitfalls additional valvular lesions, left
• Diastolic dysfunction leads to overesti- • PHT is unreliable after valvuloplasty. ventricular dysfunction and left
mation of mitral stenosis • Heavily calcified valves make PHT ventricular hypertrophy.
• Aortic regurgitation leads to underesti- unreliable
mation of mitral stenosis • Concave shape of tracing
103
011 // MITRAL STENOSIS
VALVULOPLASTY
Indication Results
Clinically significant MS (valve Good immediate results (valve area
area less than 1..5 cm2 ( 1.8 cm2 in > 1.5 cm2 without regurgitation)
unusually large patients) can be obtained in over 80%
BALLOONVALVULOPLASTY
VL
Artefact
104
011 // MITRAL STENOSIS
VALVULOPLASTY NOTES
105
011 // MITRAL STENOSIS
NOTES
106
012 // Mitral Regurgitation
CONTENT
108 Basics
118 Indications
107
012 // MITRAL REGURGITATION
NOTES BASICS
Normal Acute MR
EF 77% EF 30%
Chronic MR Decompensated MR
Echocardiography Causes
provides important clues
as to the cause of mitral Primary (structural) causes Secondary (functional) causes
regurgitation. • Mitral valve prolapse, myxomatous • Annular dilatation
Combinations of several mitral valve disease • Restrictive leaflets
etiologies are not • Flail leaflet • Systolic anterior motion
uncommon (e.g. annular • Valve fibrosis and calcification • Atrial enlargement
dilatation and restrictive • Rheumatic heart disease
leaflets). • Congenital
• Papillary muscle rupture
• Endocarditis
• Drugs
• Systemic diseases
108
012 // MITRAL REGURGITATION
QUANTIFICATION OF MITRAL
REGURGITATION – apical
four-chamber view/Color
Flow convergence Doppler
TV PMVL
Vena contracta Typical color Doppler features
AMVL of mitral regurgitation with a
prominent flow convergence
zone (PISA), a vena contracta ≥
7mm, and a jet area > 40%
of LA area.
Jet area
109
012 // MITRAL REGURGITATION
With increasing degrees of mitral regurgitation, you will first note blunted flow of
the systolic component of pulmonary venous inflow. Very severe forms of mitral
regurgitation are accompanied by flow reversal of the systolic component.
Aliasing
To calculate the • Flow through hemispheric surface =
regurgitant volume, you flow through the orifice
need to trace the mitral • Shift aliasing limit to lower velocity
regurgitation spectrum 20 – 40cm/s (larger hemisphere)
Orifice
obtained with CW • Effective regurgitant orifice area
Doppler. (EROA) = [(2r2 x Vpisa)/Vmr] Isovelocity
• r= PISA radius, Vpisa= aliasing velocity, shells
Vmr= peak MR velocity
110
012 // MITRAL REGURGITATION
Volumetric methods MR volume = MR inflow – aortic outflow (in the absence of AR)
ESC 2013
Features that Affect the Severity of Mitral Regurgitation The severity of mitral
regurgitation may differ
• Blood pressure (afterload) • Dyssynchrony markedly in one and the same
• Volume status • Anesthesia patient, especially in cases of
• Atrial fibrillation • Exercise functional mitral
regurgitation.
111
012 // MITRAL REGURGITATION
A1 P1
A2 P2
A3
MC P3
4-Chamber CS
view 3-Chamber
view
112
012 // MITRAL REGURGITATION
Prolapse
PMVL
Excentric jet
ant./med. direction
Flail
113
012 // MITRAL REGURGITATION
Posterior
jet
114
012 // MITRAL REGURGITATION
Valve perforation
(jet through leaflet)
Perforation
Perforation
115
012 // MITRAL REGURGITATION
Fail
116
012 // MITRAL REGURGITATION
117
012 // MITRAL REGURGITATION
INDICATIONS
Repair is better than Indications for Mitral Valve Surgery (ESC Class I)
replacement. Chordae
should be preserved • Surgery is indicated in symptomatic [LVESD]≥ 45 mm and/or left ventricular
whenever possible. patients with LVEF > 30% and LVESD ejection fraction ≤ 60%)
<55 mm • Mitral valve repair should be the
• Surgery is indicated in asymptomatic preferred technique when it is inten-
patients with left ventricular dysfuntion ded to last for a long time
(left ventricular end systolic diameter
ESC 2012
MitraClip Procedure
MITRACLIP – TEE 3D
surgical view
Mitral valve
orifice
Mitral valve anulus
MitraClip
118
012 // MITRAL REGURGITATION
INDICATIONS NOTES
Unsuitable valve morphology for MitraClip: The indication and suitability for
the MitraClip procedure are still
• Perforated mitral leaflet/ • Mobile length of the posterior evolving. They depend on
cleft mitral valve leaflet < 7 mm operator/center experience and
• Severe calcification in • Rheumatic thickening of the leaflets the improvments of the
the clip zone and restriction in systole and diastole, technique.
• Significant mV stenosis • Barlow‘s syndrome with extensive
(mean gradient ≥ 5 mmHg) involvement
119
012 // MITRAL REGURGITATION
NOTES
120
013 // Tricuspid Valve Disease
CONTENTS
122 Basics
NOTES BASICS
122
013 // TRICUSPID VALVE DISEASE
Tricuspid dysplasia is
common in dogs (Labrador
retrievers).
EBSTEIN’S ANOMALY –
apical four-chamber view/2D
123
013 // TRICUSPID VALVE DISEASE
QUANTIFICATION OF
NOTES TRICUSPID REGURGITATION
Dilated
RA
Vena contracta
Nyquist limit 50 – 60 cm/s <7 mm >7 mm
ESC 2013
124
013 // TRICUSPID VALVE DISEASE
QUANTIFICATION OF
TRICUSPID REGURGITATION NOTES
DIASTOLE
FEATURES OF SEVERE TR –
Enlarged RV PSAX/2D
LV
Pericardial effusion
Indications for Tricuspid Valve Surgery (ESC Class I) When patients with severe TR
develop signs of right heart
• In patients with severe primary or • In symptomatic patients with severe failure (pleural effusion,
secondary TR undergoing left-sided isolated primary TR without severe peripheral edema, ascites), it
valve surgery right ventricular dysfunction may be too late for surgery
(irreversible RV dysfunction).
ESC 2012
Adding tricuspid repair, if
indicated, during left-sided
surgery does not increase the
risk of surgery.
TRICUSPID STENOSIS
TR
125
013 // TRICUSPID VALVE DISEASE
126
014 // Prosthetic Valves
CONTENTS
128 Types of Valves
133 Complications
Manufacturer Model
Medtronic Hancock
Medtronic Mosaic
128
Valve tissue
129
Bileaflet prosthesis
Tilting disc
Medtronic Hall
Common Findings
130
Shadow
131
St. Jude Medical 1.56 ± 0.29 9.98 ± 3.62 3.49 ± 1.34 76.5 ± 17.1
Björk-Shiley 1.61 ± 0.3 10.72 ± 2.74 2.9 ± 1.61 90.2 ± 22.4
Starr-Edwards 1.88 ± 0.4 14.56 ± 5.5 4.55 ± 2.4 109.5 ± 26.6
132
COMPLICATIONS NOTES
Mechanical leaflet
Shadow
133
NOTES COMPLICATIONS
Quite often only the Mechanical Valve Obstruction – Pannus vs. Thrombus
surgeon can give the
answer if a thrombus or a Pannus Thrombus
pannus is present INR in the therapeutic range INR too low
Slow onset of symptoms Sudden symptom onset
Higher age of prosthesis Stroke/embolism
Stable gradients Variable gradients
134
COMPLICATIONS NOTES
Homograft X ---- X
Paravalvular Regurgitation
Sutures
135
NOTES COMPLICATIONS
136
Mitral Valve Repair – Ring Implantation (Annuloplasty) Mitral valve repair is always
combined with ring
• Different types of rings (flexible, open, • May resemble annular implantation.
closed) calcification on echo
• Prevents annular dilatation • The posterior leaflet may appear rather Measure the mean gradient and
short after ring implantation the pressure half-time across
the mitral valve in patients after
mitral valve repair. Undersizing
of the ring may lead to mitral
valve stenosis.
Th Th
ick i
en PM cken
AM ed VL ed
VL
Annuloplasty
ring
137
NOTES
138
CONTENTS
140 Principles of Endocarditis
TRICUSPID VALVE
ENDOCARDITIS – apical four-
chamber view RV optimized/2D
TV vegetation
Post endocarditis
Non-significant Healing with Perforation
endocardial lesion/ calcification/
fibrosis fibrosis/thickening
140
015 // ENDOCARDITIS
LA
141
015 // ENDOCARDITIS
Posterior leaflet
Anterior leaflet
TTE
High Low
142
015 // ENDOCARDITIS
MV perforation Fistula
Pseudoaneurysm – MV pseudo-
intervalvular aneurysm
fibrosa
143
015 // ENDOCARDITIS
PSEUDOANEURYSM IN
AV ENDOCARDITIS –
TEE long-axis view/2D
Pseudoaneurysm
A pulsating cavity surounds the
aortic valve (pseudoaneurysm).
Numerous vegetations are pre-
AV
sent at the aortic cusps.
Vegetation
Communication
to the left ventricle
144
015 // ENDOCARDITIS
Risk Factors
145
015 // ENDOCARDITIS
PERIANNULAR PROSTHETIC
VALVE ABSCESS – TEE short-
axis/2D
PACEMAKER/POLYMER-ASSOCIATED
ENDOCARDITIS
Clinical Presentation
146
015 // ENDOCARDITIS
PACEMAKER/POLYMER-ASSOCIATED
ENDOCARDITIS NOTES
CENTRAL LINE ENDOCARDITIS
Left atrium – apical four-chamber view/2D
&TEE bicaval view/2D
a
av
nac Central line with its tip in the
Vegetation , ve right atrium. Mobile vegeta-
Inf. Sup
tion attached to the catheter
vena cava
Mobile (thickened tip) on transthoracic
structure echo (left) and the adjacent wall
Thickened
catheter
NON-INFECTIVE/ABACTERIAL ENDOCARDITIS
Types
• Libman-Sacks endocarditis
• Marantic endocarditis • Antiphospholipid syndrome
• Hypercoagulable state
Echo Characteristics
LIBMAN-SACKS ENDOCARDITIS –
Thickened apical three-chamber view/2D
valve
Patient with lupus and antiphos-
pholipid syndrome. Several small
vegetations are seen on the
mitral valve.
Vegetations
147
015 // ENDOCARDITIS
Uncontrolled Infection
Prevention of Embolism
148
016 // Right Heart Disease
CONTENTS
150 Basics of Pulmonary Hypertension
CTEPH 1%
PAH 4%
150
016 // RIGHT HEART DISEASE
151
016 // RIGHT HEART DISEASE
ECHO ASSESSMENT OF
NOTES PULMONARY HYPERTENSION
MEASUREMENT OF SYSTOLIC
PULMONARY ARTERIAL PRES- CW sample
SURE – apical four-chamber
TR signal
view/CW Doppler TR
Peak velocity
152
016 // RIGHT HEART DISEASE
ECHO ASSESSMENT OF
PULMONARY HYPERTENSION NOTES
Quantification of mPAP
153
016 // RIGHT HEART DISEASE
ECHO ASSESSMENT OF
NOTES PULMONARY HYPERTENSION
PULMONARY ACCELERATION Sample volume
TIME (PVAT) – PSAX/PW PV
PA
PVAT is measured from the onset
to the peak of the RVOT/PV
outflow signal. In the abscence
of pulmonary hypertension, the Signal onset PVAT
peak is rather late and the curve
symmetrical.
Peak velocity
Pericardial effusion
154
016 // RIGHT HEART DISEASE
155
016 // RIGHT HEART DISEASE
Use atypical views of the • Right ventricle free wall ≥ 6mm • Measurement may be difficult;
RV (2-chamber RV view, • Use a subcostal 4-chamber view to also use visual assessment
inflow/outflow RV view). image the free right ventricle wall • Right ventricle hypertrophy may also
• Consequence of pressure overload on lead to right ventricular outflow tract
the right ventricle obstruction (narrow right ventricular
• Concentric right ventricular hypertro- outflow tract)
phy in pulmonary stenosis
ARVD may affect both • Usually autosomal dominant • 5–10% of sudden cardiac deaths
ventricles. Echo has rather • Fatty and fibrous replacement of (<65 years)
low sensitivity and specificity myocardium, especially in the right • Its prevalence is 3-fold higher in males
in subtle forms of ARVD -> ventricular outflow tract
MRI will be needed.
156
016 // RIGHT HEART DISEASE
157
016 // RIGHT HEART DISEASE
NOTES
158
017 // Aortic Disease
CONTENTS
160 Imaging of the Aorta
161 Basics
Two-chamber
Four-chamber view
view
(descending aorta)
(descending
aorta)
PLAX
Aortic Sinus of
annulus valsalva
Leading
edge
The aorta can be measured on a long- and/or Inner
short-axis view. Most reference values were edge
obtained with the leading edge method.
However, to correlate measurments better Axial view
with other imaging modalities (CT, MRI),
measurements of the inner diameters (in-
ner edge to inner edge) are applied to an
increasing extent. The difference between Leading Inner
these measurements methods is minimal edge edge
and insignificant, thanks to improved image
resolution. Longitudinal view
160
BASICS NOTES
VISUALIZATION OF
THE ASCENDING AORTA –
modified PLAX/2D
ESC 2010
AORTIC ANEURYMS
Definitions
True aneurysm
Localized dilatation > 50% of the reference
segment (circumscribed or diffuse aneurysms)
Aortic ectasia
Arterial dilatation of less than 150% of the
normal arterial diameter
161
162
ACC 2010
163
Stanford classification
A A B
Ascending Descending
Type A involves the ascending aorta, type B only the descending aorta
DeBakey classification
I II III
Ascending Ascending Descending
Descending
Type I involves the ascending and the descending aorta, type II only the ascending
aorta and type III only the descending aorta.
164
165
Aortic Syndromes
Bleeding into the aortic wall (such as Plaque rupture, penetrating ulcers,
after plaque rupture) causes an intramu- and intramural hematoma may lead to
ral hematoma. aortic rupture.
166
167
168
CONTENTS
170 The Pericardium
Visceral layer
PERICARDIAL EFFUSION
The cause of pericardial effusion • Idiopathic: no cause is found despite • Autoimmune disease: particularly:
depends on the setting of your lab full diagnostic investigation systemic lupus erythematodes,
and the part of the world you practice • Infectious: common in viral infection rheumatoid. arthritis., systemic
in (e.g. tuberculosis in developing (direct + immune response) sclerosis
countries, iatrogenic when • Iatrogenic: pacemaker, catheter • Radiation: 20% develop constriction
interventions and cardiovascular procedures, biopsy, cardiac surgery • Rheumatic: usually small
surgery are performed at your • Neoplastic: often hemorrhagic, pericardial effusion
center). denotes poor prognosis • Traumatic: contusio cordis or heart/
• Myocardial infarction: myocardial aortic rupture
The cause of effusion may remain rupture, epistenocardic (early) + • Endocrine disorder: e.g. myxedema
unclear because the diagnosis would Dressler syndrome (late) • Pulmonary hypertension: the
require peri-and/or myocardial • Renal failure: uremia- or dialysis- mechanism is unclear (poor prognosis)
biopsy as well as cytological, associated • Post cardiac surgery: usually hemat-
histoimmunological, and oma, often localized
microbiological analysis of the fluid. • Aortic rupture: hemorrhagic
effusion, pericardial effusion in 45%
of dissections.
170
Liver
PERICARDIAL EFFUSION –
Pericard subcostal four-chamber view/2D
ial effusi
on
Fibrin strand Large circumferential pericardial
effusion with fibrin strands. The
RV image loop shows swinging heart
motion.
LV
171
Epicardial border
Small circumferent
Localized
172
PERICARDIAL EFFUSION
NOTES
SEQUENTIAL IMAGES OF PERI-
CARDIAL EFFUSION – PSAX/2D
PERICARDIAL TAMPONADE
173
RV LV RV LV
RA LA RA LA
Symptoms Signs
Pain Tachycardia
Dyspnea Edema
174
PERICARDIAL CONSTRICTION
175
Types of Constriction
176
RA
Pe
ric
ar
d
cy ial
st
177
NOTES
178
CONTENTS
180 Pseudotumours
181 Masses
179
Eustachian
valve
LIPOMATOUS INTERATRIAL
SEPTUM – TEE bicaval view/2D
Right atrium
180
PSEUDOTUMOURS NOTES
ABBERANT CHORD –
apical four- chamber view/2D
Aberrant
chord
MASSES
Distinguish between
Fever/infection X
Embolism X (X) X
Spontaneous contrast x
Combine clinical and morphological clues to determine the etiology of the mass.
181
NOTES MASSES
THROMBUS IN LEFT
ATRIAL APPENDAGE/atypical api-
cal four-/two-chamber view/2D
PV
LA
182
MASSES NOTES
3% 5% 1% 13 %
2%
5 % 15 %
16 %
46 % 15 %
46 %
21 %
MYXOMA – zoomed
MV
apical four- chamber view/2D
IAS
183
NOTES MASSES
FIBROELASTOMA (AORTIC
VALVE) – apical three-cham-
ber view/2D
Fibroelastoma
Small mass on the ventricular
aspect of the aortic valve,
which was histologically AMVL
proven to be a fibroelasto-
ma. Fibroelastomas may also
appear as pedunculated or
berry-like structures. AV
184
MASSES NOTES
Imaging Tips for the Evaluation of Masses Malignant tumors of the right
atrium tend to grow along the
• Use atypical views focusing on the whether the tumor is vascularized and interatrial septum. Look closely
mass whether there is flow within the tumor. at this structure when you see a
• Do not be too focused on the tumor • Use echo contrast. It helps to delineate mass in the right atrium.
– perform a complete exam the tumor and determine whether the
• Use different gain settings. In- tumor is vascularized.
tramyocardial tumors are sometimes • Do not forget to point the transducer
difficult to see. to the liver, the inferior vena cava, and
• Use color Doppler. It may help to tell the pleura.
185
NOTES
186
CONTENTS
188 Basics
NOTES BASICS
Primum defect
Coronary sinus defect
Sinus venosus
defect (inf.)
188
020 // CONGENITAL HEART DISEASE
ASD I
LA
RA
189
020 // CONGENITAL HEART DISEASE
A warning note: Even small defects can generate significant left-to-right shunts
when the gradient between the left and the right atrium is high.
ASD closure must be avoided Indications for ASD closure (ESC Class I)
in patients with Eisenmenger • Patients with significant shunts (signs • Device closure is the method of
(right-to-left shunt) of RV volume overload) and pulmo- choice for secundum ASD closure
syndrome (ESC Class III). nary vascular resistance < 5 Wood when applicable.
units, regardless of symptoms.
ESC 2010
190
020 // CONGENITAL HEART DISEASE
LV
RA
Amplatzer
• Look for a residual shunt using color • Location and stability of the device
Doppler (reduce PRF) and echo • Thrombus on the device
contrast • Pericardial effusion
191
020 // CONGENITAL HEART DISEASE
Epidemiologic Facts
192
020 // CONGENITAL HEART DISEASE
Views and Locations of the Various VSD Types If you are not sure
whether a VSD is present
use the good old
RVOT RVOT
stethoscope!
TV
Ao
LV PV
RA
MV
LA PA
LA
LV LV
RV RV
RV
TV MV TV MV
LV
Ao
RA LA RA LA
Perimembranous
Outlet infracristal
Outlet supracristal
Inlet
Trabecular
Perimembranous or Outlet
PERIMEMBRANOUS VENTRIC-
ULAR SEPTAL DEFECT – PSAX/
color Doppler
LA
193
020 // CONGENITAL HEART DISEASE
Double chambered RV
194
020 // CONGENITAL HEART DISEASE
Ao
CORONARY FISTULAS
195
020 // CONGENITAL HEART DISEASE
• Stenosis of the pulmonary artery (right • Deviation of the origin of the aorta to
ventricular outflow obstruction) the right (overriding aorta)
• Ventricular septal defect • Concentric right ventricular
hypertrophy
196
020 // CONGENITAL HEART DISEASE
Overriding aorta
RA Tricuspid
LV valve
Mitral valve
RV RV
LV
D-TGA L-TGA
• Lesion in which the aorta arises from corrected TGA. Venous blood returns Patients with L-TGA are at
the right ventricle and the pulmonary from the correctly located right atrium risk for (systemic) heart
artery from the left ventricle. to the discordant left ventricle via the failure because the morpho-
• Its prevalence is 4.7 per mitral valve and into the lung via the logical right ventricle (which
10,000 live births. pulmonary artery. Oxygenated blood was not formed to sustain a
• It is not associated with any flows through the pulmonary veins to high pressure system)
common gene abnormality. the left atrium into the discordant right supplies the systemic
• The most common form is the dextro ventricle, and via the tricuspid valve into circulation.
type (D-TGA), in which the aorta arises the systemic circulation through the
from the right ventricle and the aorta (atrioventricular and ventriculoar-
pulmonary artery from the left ventricle terial discordance).
(ventriculoarterial discordance). • The D-TGA leads to cyanotic heart
• Levo- or L-looped transposition of the disease while L-TGA usually does not
great arteries (L-TGA) is very rare and is present with cyanosis (unless the
commonly referred to as congenitally patient has associated cardiac defects).
197
020 // CONGENITAL HEART DISEASE
• Subcostal views show the pulmonary • Parasternal short-axis views show the
artery arising from the posterior left aorta rising anteriorly from the right
ventricle. ventricle.
• Look for associated cardiac lesions.
L-TGA –
Apical four-chamber view/2D
198
020 // CONGENITAL HEART DISEASE
PA
RA
Mitral valve
199
020 // CONGENITAL HEART DISEASE
NOTES
200