Echocardiography Function Guiline Image 추가

Cardiac Measurements
 Cardiac Chamber Quantification

 Hemodynamics
Clinical SpecialistT
ALPINION Medical eam SpecialistTeam
Systems , Clinical
Echocardiography
• Method: transthoracic, transesophageal, intra-cardiac
• Type: 2D, M-mode, Dolor Doppler, Tissue Doppler, 3D
• Structure; Chamber size, valves, neoplasm, pericardium great vessels, IVC, SVC
• Function ; Systole, Diastole
Hemodynamics
ALPINION Medical Systems, Clinical SpecialistTeam

Transducer for Echocardiography
MP 1-5X SP 1-5/SP1-5 P 1-5CT

NNN SP1-5T
Single Crystal Phased Array Single Crystal Phased Array Phased Array
Application : Adult Echo, TCD, Application : Adult Echo, TCD, Application : Adult Echo, TCD,
Pediatric Echo Pediatric Echo Pediatric Echo,
CW2.0 CW5.0
Pencil Type probe Pencil Type probe

Application : Vascular, valvular Dopp Application : Vascular,
ler study, Doppler spectrum only Doppler spectrum only

Features: Harmonic Imaging Technology
• Filtered Tissue Harmonic Imaging transmit : fₒ
- low frequency
- good penetration
receive : fₒ & 2fₒ
Transmit/Receive Receive Receive &Cut off : fₒ

Use: 2 fₒ
-week penetration but clear
Features: Harmonic Imaging Technology
• Pulse Inversion Harmonic Imaging
- Eliminate fundamental signal by summation
- Frame rate becomes half of its original frame rate
cancel fundamental tissue signal
remain 2nd harmonic signal

ALPINION Medical Systems , Clinical SpecialistTeam
Anatomy and blood Circulation of the heart
ALPINION Medical Systems, Clinical Specialist Team

The Conduction System of the heart
a group of specialized
cardiac muscle cells
send signals to the
heart muscle,
cause to contract ;
SA node
-> AV node
-> Bundle of His
-> bundle branches
-> Purkinje fibers

The Conduction System of the heart & ECG
Intracardiac tracings show the normal intervals between
• P: atrial depolarization
• PQ segment: SA node to AV node
• QRS complex: ventricular depolarization
• ST segment : ventricular depolarization
• T : ventricular repolarization

Parameters for2D
• Image “Depth”: 15-16 cm for Parasternal Long Axis view, 17-18cm for Apical View
• Frequency : Harmonic 3.6MHz/Harmonic 3.2Mhz/2Mhz
• Focus : LV posterior wall
• Dynamic Range: 60 - 72dB
Parameter Effect Parameter Effect

Frequency The higher frequency, the finer image Harmonic Enhance the contrast resolution
with fine tissue differentiation
Dynami Between the highest and the Rejection Suppress below a certain level of
c Range lowest signal value in system. echo information
Use optimizing tissue texture
Focus Enhance the resolution around focus SRI Unnecessary speckle noise
range reduction imaging
Persist Provides smoothing effect by Full SRI Option further steps of SRI
frame averaging, no affect frame
rate
Line Density the more line density, the more spatial Gray Map Display intensity to variable
resolution . Trade off Frame rate brightness

Parameters for the color
parameter Increase
Frequency Determine maximum velocity range, low frequency is available to the pixel size becomes
process higher velocity fine and small
PRF Determine color scale ( velocity) Send more PRF,
Wall filter Filter our clutter signals caused from vessel movement For high dynamic organ
needs, such as heart
Persist Provides smoothing effect by frame averaging, not affect frame Remaining image
rate
Threshold threshold assigns the color information to stop at which gray scale Display color on bright B-
mode
Type Velocity, velocity variance ( directional power doppler), Power VV & PD for low velocity
doppler (intensity ). detection or renal flow
Ensemble packet size , 8-10 for cardiac, 14 for vein, 12 for renal Reduce frame rate
Smooth The higher, the finer margine
Angle steer Align to the flow direction -20⁰/ 0⁰/ 20⁰, -9/0/+9 Perpendicular flow to
transducer’s insonation
Line density Same as 2D –mode. . The more the detail
resolution

Characteristics of Doppler
Color Power Doppler Pulsed wave Continuous wave

direction flow detection, sample volume unknown gate,
directional flow ( gate) , velocity detect high velocity
range (regurgitation,
stenosis)
Mean velocity Intensity Target velocity Max velocity

Scanning Tips : Positions
Suprasternal
Notch
Rt.
Parasternal Lt. Paraste
rnal
Apical
Subcostal
/Xiphoid
ALPINION MedicalSystems, Clinical Specialist Team

Basic Echocardiographic Views
1. PLAX view
2. PSAX view
3. Apical view

5. Suprasternal view
4. Subxiphoid view

Rotation probe
Sliding probe
Rocking manuever
Angling probe
Parasternal Long Axis view
• Transducer position: left sternal
intercostal spce 2-5th
• horizontally to keep the interventricular
RV
septum and the Aortic wall
LV Ao.V • Size and thickness of the septum and
posterior wall
MV LA • Motility of the LA, LV
• Changes of the Aortic Valve
• Measure ascending aorta at each point
• Pericardial effusion

Parasternal Long Axis view
Zoom : contain the aortic valve and

the mitral valve
• Measure LVOT diameter for
LVOT stroke volume
= 0.785*D²*LVOTTVI
• Cine save for the mitral valve and its
apparatus` morphology
2015 ASEGUIDELINES and STANDARDS

Parasternal Short Axis view
• Turn a transducer to clockwise
around 90 ⁰ from PLAX
• Aortic valve level
• Mitral valve level
• Papillary muscle level
• Apex level

Aortic Valve level
• Measure “ RV” dimension and

“RVOT” dimension
RV • Identify the aortic valves; 3 cusps,
Pul. Valve calcification, LAD os
TV
Ao.
RA V
I
LA
A
S
LAA

Mitral Valve, Papillary musclelevel
• Wall motion, wall thicknes
s degenerative changes
• If there were pressure overload,
LV looks “ D” shape
RV
LV

Apical view - the left ventricle
2015 ASE GUIDELINES and STANDARDS
• Measure Ejection Fraction

at 4chamber and 2chamber view
• Measure RV size

Apical view – the right ventricle
• Measure RV dimensions at
• modified 4chamber
• Measure RIMP with doppler , TAPSE with M-mode
The Right Ventricle : Dimensions
RVD2
RVD1
- RVD1 : maximal transverse dimension in the basal 1/3 of RV inflow

in RV focused view ( slightly off-axis 4 Chamber view )
- RVD2 : transverse RV diameter in the middle third of RV inflow

The Coronary circulation
• the circulation of blood in the blood vessels of the heart muscle

Coronary territory and wall motion
Typical distribution
• LAD, The left anterior
descending coronary
artery
• The circumflex
• The right coronary artery

13 1 7
14 6 12 13
16 8 16
2
15 5 11 14
3 9 15
10
4


Subcostal view- M-mode
• Measure a diameter of the IVC

• Record diameter changes during inspiration and expiration
• Make a “New Measurement” under name of “IVC”

Suprasternal viewDoppler
• Incaseof Aorticregurgitation,tomeasurevelocityofthe DescendingAorta

Measurements & Calculation

TheConductionSystemof theheart& ECG
Intracardiac tracings show the normal intervals between
• P: atrial depolarization
• PQ segment: SA node to AV node
• QRS complex: ventricular depolarization
• ST segment : ventricular depolarization
• T : ventricular repolarization

Chamber Quantification & Great Vessel
The Left Ventricle size and thickness
The LV Global Systolic Function
LV Regional Function LV Mass
The Right Ventricle
RV Systolic Function
The Left and Right Atria
The Aortic Annulus and Aortic Root

Set Up : 2D Measurement

Set Up : Doppler Measurement
• Different from system to system

Cardiac Function – Systolic function
Left Ventricular function

• Systolic function
- Fractional shortening, Ejection Fraction
- Tissue Doppler Imaging
- Myocardial Performance Index
- dp/dt using mitral regurgitation
- Newer techniques
 Strain imaging
• Diastolic function
Right Ventricular function

• Systolic function
- Annular velocity, FAC, RIMP, TAPSE

Systolic function: LV volume
• Systolic Function ≈ Ejection Fraction

• Evaluated by Simpson’s Method
• Assessment of left ventricle systolic function is
an important clinical variable with respect to
diagnosis, prognosis and treatment
EDV – ESV x 100 EF

EDV

Systolic function : Internal linear dimension
• Left Ventricle M - mode

- Place ( M-line) over the mitral valve leaflet tip, perpendicular 90 ⁰ to the LV
axis
- Perform M-mode by pressing “M” knob

Systolic function : Internal linear dimension
IVSs
LVEDd LVEDs
PWTs
• Measurement -> Teichholz

• set cursor at “R” point on ECG for diastole measure
• Start from “RVID”, or select “Diastole” measure from “ IVSd”
• Place a cursor from IVS upper end -> “Set” drag another cursor to the
lower end of IVS -> “Set”, drag a cursor to LVID-> “Set”, drag a cursor
to LVPW->”Set”
• press “Systole” and repeat from IVSs through LVPWs
***Turn On/Off each measurement item on “System Preset”
-> “ Measurement” -> “Labeled Measure”
Systolic function: LV fractional shortening
Truly perpendicular to the long axis of the left ventricle

• Fractional Shortening of LV : ( LVIDd – LVIDs ) / LVIDs *100
• Calculation of relative wall thickness with the formula
( 2 x posterior wall thickness )/ ( LVIDd at end –diastole)
Female Male
Relative wall thickness (cm) 0.22-0.42 0.24-0.42
Septal thickness (cm) 0.6-0.9 0.6-1.0
Posterior wall thickness (cm) 0.6-0.9 0.6-1.0

Systolic function: LV dimension, volume
• EF by M-mode
- Teichholz or Quinones method
- Not recommended by 2015 ASE
contraction Relaxation
ejection filling
AO AC
AV
MC
MV MO
IVS
PW
LA filling LA emptying


Biplane Simpson’s method (Modified Simpson’s method)
• LV volumes is measured form annulus to annulus tracing along the
endocardial border of the LV

Systolic function: LV Ejection Fraction
Biplane Simpson’s method (Modified Simpson’s method)
• LV length is defined as the distance between the center of the mitral ann
ular ring and the apex
• Once “EDV4” is done ->“Priority” for change phase -> Trackball to search
end-systole -> “Measure “ -> select “ESV4” -> repeat trace

• LV Volume
- Calculated from the dimension and area
- Apical 4 chamber and 2 chamber views
- Modified Simpson’s method or disk summations method
Normal values for 2D echocardiographic parameters of LV size and function according to gender, 2015 ASE
Male Female
Parameter Mean ± SD 2-SD range Mean ± SD 2-SD range

LV internal dimension
Diastolic dimension (mm) 50.2 ± 4.1 42.0 -58.4 45.0 ± 3.6 37.8 – 52.2
Systolic dimension (mm) 32.4 ± 3.7 25.0 -39.8 28.2 ± 3.3 21.6 – 34.8
LV volume (biplane)
LV EDV (mL) 106 ± 22 62 -150 76 ± 15 46 -106
LV ESV (mL) 41 ± 10 21 -61 28 ± 7 14 - 42
LV volume nomalized by BSA
LV EDV (mL/m²) 54 ± 10 34 -74 45 ± 8 29 -61
LV ESV (mL/m²) 21 ± 5 11- 31 16 ± 4 8 - 24
LV EF (biplane) 62 ± 5 52 -72 64 ± 5 54 - 74

Systolic function: LV mass

Systolic function: LV mass
Normal ranges for LV Mass indices
Female Male
LV mass(g) 66-150 96-200
LV 44-88 50-102
mass/BSA(g/m²)
• Parasternal short axis view

• Select “ T-E method ” or “Area-Length method”
• Measure outer circle for “A1” exclude papillary muscle
, inner circle for “A2”
• Go to apical 4 chamber view
• Measure “LV dimension” from apex to mid annular point
• Use BSA index
Systolic function: Annular tissue doppler
• Activate color TDI and apply to myocardial septal wall
• Press PW with sample volume by 4mm at junction of mitral annulus to septum
S`

Systolic function: Myocardial Performance Index
• LV MPI : normal value 0.35 ± 0.05
- place PW gate between the mitral and the aortic valve
- measure the time at mitral closing point to next opening
- measure the LV ejection time
MPI = (a –b) / b = ( IVCT +IVRT ) / ET

Systolic function: MR dp/dt
• dP/dt in Mitral Regurgitation flow
- Obtain CW spectral from the mitral regurgitation jet
- open an measurement item “ MR dp/dt” from MR
- bring a cursor at 1 m/sec point on the MR CW spectrum
- Then, place another cursor at 3m/sec on the same MR CW
1m/sec
3m/sec

LV Systolic function :
Normal ranges and severity partition cutoff values for 2DE-derived LV EF and LA volume, 2015 ASE
Male
Parameter Normal Mildly abnormal Moderately Severely

abnormal abnormal
LV EF (%) 52-72 41-51 30-40 <30
LA volume/BSA (mL/m²) 16-34 35-41 42-48 >48
Feale
Parameter Normal Mildly abnormal Moderately Severely

abnormal abnormal
LV EF (%) 54-74 41-53 30-40 <30
LA volume/BSA (mL/m²) 16-34 35-41 42-48 >48
Strain (%) = (L t - L0 )/ L0
• GLS measurements should be made in the 3 standard apical long axis, 4 chamber,
and 2 chamber views and averaged
• A peak GLS in the range of -20%
• The lower the absolute value of strain, the more likely abnormal

Echocardiograph for Diastolic function
Left Ventricular function

• Diastolic function
- adequate filling of the ventricle during rest and exercise
without abnormal increase in diastolic pressure

Diastole in Cardiac Cycle
AV Close
AV Open
Ao Pressure
MV Close
MV Open
LA Pressure
LV Pressure
Diastole
IVR
IVC
T
T
Rapid Slow Atrial
Filling Filling Filling
Diastole Systole
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eam
Echocardiograph for Diastolic function
• Determinants of LV filling
- active myocardial relaxation
- LV compliance
- LA function
- heart rate
- pericardium

Pressure gradient during diastole phases
MV Eflow MV A Flow
LVend- di
LVmin. Pre A. p astolic P.
pressure ressure
MV A Flow
MV Eflow

Echocardiography for Diastolic function
• LA Volume
• Isovolumic Relaxation Time
• Mitral inflow
- initial low pressure filling : E wave
- active atrial contraction : A wave
• Pulmonary vein flow
• Tissue Doppler : E`

Pressure - Volume curve in Cardiac Cycle
LVP>AoP
LAP>LVP

Diastolic function: LA volume
Ao.valve
Left Atrium
• Measure the Aortic valve and the Left atrium

- Keep M-line 90 ⁰ to Aorta/Left Atrium wall
- “ Measure ” -> Ao/ LA folder
- Put a cursor edge to edge

Diastolic function: LA volume
• Select 1 of “LA Vol(Simp)” measurements
- place a cursor on mitral annulus-septal wall -> trace to opposite site
Normal Mildly Moderately Severely
range abnormal abnormal abnormal
Male 16-34 35-41 42-48 48>
Female 16-34 35-41 42-48 48>
LA volume/BSA (ml/m²)

Diastolic function: Mitral flow
• Mitral Inflow ; Peak E vel., Deceleration Time, Peak A vel., IVRT

• Sample volume; 2-3mm, locates at between 2 leaplets ` tip
Otto. Text book of Clinical Echocardiography,5th
Evel.
Dec A vel.
Time

Diastolic function: Mitral flow
• Mitral Inflow ; Peak E vel., Deceleration Time, Peak A vel., IVRT

• Sample volume; locates SV between LV outflow and MV inflow
E vel.
IVRT

Diastolic function: Tissue velocity at mitral annulus
• TDI : Ea Vel or MV Ea Vel.
E/E’ value : 8 normal 15> abnormal
• E` < 8.5Cm/sec, E`/A` <1
• usually lateral TDI shows higher velocities than septal
S`
a`
e`
Tissue Doppler Imaging

Diastolic function: Pulmonary vein flow
• Pulmonary vein flow ; systolic Vel., diastolic Vel., A vel. & duration
• Measure item under “ PVe”
• Sample volume ; 2-3mm, below into pulmonary vein 0.5cm
S D
S2

Normal Values for Doppler- derived diastolic m.
Age Group
Measurement 16-20 21-40 41-60 >60
IVRT(ms) 50 ±9 (32-68) 67± 8(51-83) 74 ±7(60-88) 87 ±7(73-101)

E/A ratio 1.88±0.45 1.53±0.4 1.28±0.25 0.96±0.18
(0.98-2.78) (0.73-2.33) (0.78-1.78) (0.6-1.32)
DT(ms) 142±19(104-180) 166±14(138-194) 181±19(143-219) 200±29(142-258)
A duration (ms) 113±17(79-147) 127±13101-153) 133±13(107-159) 138±19(100-176)

PV S/D ration 0.82±0.18 0.98±0.32 1.21±0.2 1.39±0.47
(0.36-1.18) (0.34-1.62) (0.81-1.61) (0.45-2.33)
PV Ar (cm/sec) 16±10(1-36) 21±8(5-37) 23±3(17-29) 25±9(11-39)
PV Ar duration(ms) 66±39(1-144) 96±33(30-162) 112±15( 82-142) 113±30(53-173)
Septal e` (cm/sec) 14.9±2.4 15.5±2.7 12.2±2.3 10.4±2.2

(10.1-19.7) (10.1-20.9) (0.5-1.7) (6.2-14.6)
Septal e`/a` ratio 0.85±0.2
2.4 1.6±0.5(0.6-2.6) 1.1±0.3(0.5-1.7)
(0.45-1.25)
Lateral e`(cm/sec) 20.6±3.8(13-28.2) 19.8±2.9 16.1±2.3(11.5-20.7) 12.9±3.5
(14-25.6) (5.9-19.9)
Latera; e`/a` ration 3.1 1.9±0.6(0.7-3.1) 1.5±0.5(0.5-2.5) 0.9±0.4(0.1-1.7)

Echocardiographic classification of diastolic dysfunction

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Diastolic Function – Valsalva maneuver
• Valsalva maneuver decrease preload during strain phase
• Peudonormal mitral inflow changes to a pattern of impaired relaxation
• The E/e′ ratio was markedly increased, using e′ from either side of the annulus
Mitral Inflow
mmHg
LV
LA
cm/sec
Mitral annulus

Diastolic function : Mitral Inflow
 Key Points
1. PW Doppler is performed in the apical 4-chamber view to obtain mitral inflow
velocities to assess LV filling.
2. a 1-mm to 3-mm sample volume is placed between the mitral leaflet
tips during diastole to record a crisp velocity profile.
3.Primary measurements include peak E and A velocities, E/A ratio, DT, and IVRT
4.Mitral inflow patterns include normal, impaired LV relaxation, Pseudonormal
flow, and restrictive LV filling.
5.In patients with dilated cardiomyopathies, filling patterns correlate better
with filling pressures, functional class, and prognosis than LV EF.
6.In patients with coronary artery disease and those with hypertrophic cardio
myopathy in whom the LV EFs are 50%, mitral velocities correlate poorly wi
th hemodynamics.

Create New measurement

Tricuspid Annular Plane Systolic Excursion:TAPSE
• RV dimensions at modified 4chamber

- M-mode aligned along the direction of tricuspid lateral annulus
- good correlations with parameters estimating RV global systolic
function
- TAPSE <17mm is highly suggestive of RV systolic dysfunction

Systolic function - Right Ventricle
RV Systolic function ;RIMP by TDI or Tricuspid & pulmonary outflow
• Measure at 4chamber and short axis view
• Measure
• RIMP>0.43 by PW, >054 by TDI indicate RV dysfunction
RIMP = TCO – RVET

RVET
TV closing to
opening duration
RV ET
The Right Atrium
• Measure the Right Atrial volume
- Linear dimension ; minor axis is measuredbetween the lateral RA wall
and interatrial septum at the mid atrial level
- Area ; by tracing the RA blood-tissue interface
- Volume; single plane area-length method
• Normal ranges
Women Men
RA minor axis, d (cm/m²) 1.9±0.3 1.9±0.3
RA major axis, d (cm/m²) 2.5±0.3 2.4±0.3
2D RA volume (mL/m²) 21±6 25±6
RA

Aortic annulus & Aortic Root diameter
horizontally to keep the interventricular septum and the Aortic wall
• Measure ascending aorta at each point
• LVOT, Aortic Sinus, Sinotubular junction, Ascending Aorta
• Pericardial effusion

Left Ventricular Outflow Tract- diameter
Zoom : Including the aortic valve and

the mitral valve
• Measure LVOT diameter for
LVOT stroke volume
= 0.785*D²*LVOTTVI
• Cine save for the mitral valve and
its apparatus` morphology
2015 ASEGUIDELINES and STANDARDS

Color image - low PLAX and Apical window

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Echocardiographic evaluation
• Echocardiographic evaluation of cardiac adaptation to the volume overload

offers, along with careful assessment of symptoms, and ideal tool for manag
ement of valvular regurgitation and timing of surgery
• 2D echocardiography provides an assessment of valvular structure,

mechanism of regurgitation and adaptation to the volume overload state
• Doppler has become the first line approach to the evaluation and management
of valvular heart disease
• Doppler allows a comprehensive evaluation of the severity of regurgitation

using qualitative and quantitative methods from Color flow and spectral Do
ppler

Derived Doppler Equation
Basic measurement Doppler Equation

-. Bernoulli equation
Pressure Gradient= 4V² ±∆f = f r – f 0
∆f = 2 f 0 Vcosθ
C
C ∆f
V=
2 f 0 cosθ

Derived Doppler Equation
Advanced Measurements Doppler Equation

-. Continuity Equation
-. Valve area, Shunt Study
-. PISA method V1 V2
CSA1 CSA2
Velocity
V2
V1
TVI2
TVI1
Time
Q1 = Q2
CSA1 x TVI1 = CSA2 x TVI2

Calculation : LV stroke volume
• measure stroke volume of the Left heart
- put a pw gate on LVOT at apical 3 or 5 chamber view
- Trace from open to close of LVOT spectrum
LVOT
VTI
Apical 3/5chamber

Calculation : Aortic Valve Area
 Continuity Equation
• measure “2D” at LVOT Diameter in PLAX
• measure VTI at LVOT(PW) in apical 5 chamber
• measure VTI at Aortic Valve (CW) in apical 5 chamber
AVflow= LVOTflow
LV CSAAV x TVIAV = CSALVOT x TVILVOT
LVOT
CSALVOT
LA Volume
CSAAV
Ao
volume

RV Systolic Pressure - Tricuspid Regurgitation
LV RV
LA
RA

RVSP - Tricuspid Regurgitation
• Right Ventricle Systolic Pressure
- when Tricuspid regurgitation displayed on color mode
• Place the cursor of CW doppler on the vena contracta -> press CW
• Calculate : Right Ventricle Systolic Pressure
- “Measurement” -> ‘RVSP” -> measure “TR V max .”
- select 1 of 5 , 10, 15, 20mmHg for “RAP”
• Pulmonary hypertension > 35~40mmHg
RVSP = 4V 2 + PRA
RVSP = 4 X (3.0)²+ RA Pressure
TR Vmax

Grading tricuspid regurgitation severity
Parameters Mild Moderate Severe
Tricuspid valve Usually normal Normal or abnormal Abnormal/Flail leaflet/

poor coaptation
RV/RA/IVC size Normal Normal or dilated Usually dilated
Jet area-central jets <5 5-10 >10

(cm²)
VC width Not defined Not defined, but < 0.7 >0.7
PISA radius (cm) ≤ 0.5 0.6~0.9 >0.9
Jet density and contour- Soft and parabolic Dense, variable contour Dense, triangular with
CW early peaking
Hepatic vein flow↑ Systolic dominance Systolic blunting Systolic reversal

RVSP – RA pressure
IVC
• IVC diameter<2.5cm, change according to respiration -> normal RA Pressure
• Hepatic vein flow in severe TR, hepatic venous flow reversal in systole (S)
Hepatic vein
Liver Liver
Liver
Liver
IVC
IVC RA
RA
Inspiration Expiration
IVC
S D

Pulmonary Artery Pressure

Calculation: Pulmonary Artery Pressure
• Mean PA pr= 4 (Vpeak)2

• PA end-diastolic pressure
= 4 (VED)2 + RVEDP
= 4 (VED)2 + RA pressure
Peak
+
End Dia
+

Aortic Stenosis
• Incase of Aortic Valve Stenosis, planimetry method is used at 2D

- Draw along the open edge of the aortic valve

Aortic Stenosis – mean pressure gradient
Hemodynamics AVA
mild Mean <20 >1.5cm²
Mod. 20-40mmHg 1.0-1.5
severe Mean > 40 <1.0
• Trace the aortic valve VTI, after acquisition a doppler image by CW

Aortic Valve Area : Doppler
Continuity Equation
• measure “2D” at LVOT Diameter in PLAX
• measure “VTI at LVOT(PW”) in apical 5 chamber
• measure “VTI at Aortic Valve (CW)” in apical 5 chamber
LV
LA LVOT C S A LVOT
Volume
CSAAV
AV
Volume
CW through the AV

Aortic Regurgitation – Pressure Half Time
LV
AV
LA
+
+
• measure “ AI Pressure Half Time”

• steep deceleration rate of the AR velocity by CW Doppler, and a holodiastolic flow
reversal in the descending (desc.) aorta in severe AR
Aortic Regurgitation : Severity by Doppler
• In severe Aortic regurgitation, measure the VTI of reverse flow at the

Descending Aorta

Grading of aortic regurgitation severity
Mild Moderate Severe
Structural parameters
LA size Normal Normal or dilated Usually dilated
Aortic leaflets Normal or abnormal Normal or abnormal Abnormal / flail, or wide
coaptation defect
Doppler Parameters
Jet width in LVOT- Small in central jets intermediate Large in central jets;
color flow variable in eccentric jets
Jet density - Incomplete or faint Dense Dense
CW (PHT, ms) Slow > 500 Medium 500-200 Steep < 200
Diastolic flow reversal in
descending aorta -PW Brief, early diastoic Intermediate Prominent holodiastolic
reversal reversal
Quantitative parameters
Vena contracta width, cm < 0.3 0.3-0.60 > 0.6
Jet width/LVOT width, % < 25 25-45 46-64 ≥ 65
Jet CSA/LVOT CSA, % <5 5-20 21-59 ≥60
Reg. Volume, ml/beat < 30 30-44 45-59 ≥ 60
Regurtant Fraction, % < 30 30-39 40-49 ≥ 50
EROA, cm² < 0.10 0.10-0.19 0.20- 0.29 ≥ 0.30
Grading of aortic regurgitation severity

Mitral Stenosis
• Incase of Mitral Valve Stenosis, planimetry method is used at 2D

• Also measure the left atrium size

Mitral Stenosis – mean VTI, Mitral valve Area
• Incase of Mitral Valve Stenosis, trace the mitral valve inflow

• Also measure the pressure half time for mitral valve area

Regurgitation Volume by PISA
Continuity Equation
Mitral Regurgitation Volume by Proximal Isovolumetric Surface Area
• MR flow = PISA flow

• ERO (Effective Regurgitant Orifice) E
RO x MR Vel. = 2 x π x R² x Alias Vel.
ERO = 2 x π x R² x Alias Vel.
MR max Vel.

PISA method
radius • Optimize regurgitant flow→ Zoom up
• baseline shift of color hue to
describe the aliasing velocity up
baseline
shift to 30~40cm/s
ERO • Measure PISA radius & select
Aliasing Vel ‘PISA(MR)- aliasing Vel’
ocity (Va)
regurgitation
volume

• Trace “ MR VTI” and “ Vmax” by CW Doppler

- place a cursor at the vena contracta, perform CW, and trace along borderline

Grading of mitral regurgitation severity
Structural parameters
LA size Normal Usually dilated** Usually dilated**
LV size Normal Usually dilated** Usually dilated**
Mitral leaflets or Normal or abnormal Normal or abnormal Abnormal/
support apparatus Flail leaflet/
Ruptured papillary muscle
Doppler parameters
Color flow jet area Small, central jet variable Large central jet (usually
(usually < 4cm² or >10cm² or > 40% of LA
<20% of LA area) Area or variable size wll-
Impinging jet weirling in LA
Mitral inflow A wave dominant Variable E wave dominant
(E usually 1,2 m/s)
Pulmonary vein flow Systolic dominance Systolic blunting Systolic flow reversal
Quantitative parameters
VC width (cm) <0.3 0.3-0.69 ≥0.7
R Vol (ml/beat) <30 33-44 45-59 ≥60
RF (%) <30 30-39 40-49 ≥50
EROA (cm²) <0.20 1.20-1.29. 0.30-0.39 ≥0.40
Grading of mitral regurgitation severity
Specific signs of • Small central jet < 4cm² Signs of MR >mild present, • Vena contracta width ≥ 0.7cm
severity or <20% of LA size but no criteria for severe MR with large central MR jet ( area
• Vena contracta width >40% of LA) or with a wall-
<0.3cm impinging jet of any size,
• No or minimal flow swirling in LA
convergence • Large flow convergence
• Systolic reversal in pulmonary
veins
• Prominent flail NV leaflet
or ruptured papillary muscle
Supportive signs • Systolic dominant flow in Intermediate signs/ findings • Dense, triangular CW
pulmonary veins Doppler MR jet
• A-wave dominant mitral • W-wave dominant mitral
inflow inflow ( E>1.2m/s )
• Soft density, parabolic CW enlarged LV and LA size
Doppler MR signal ( particulary when normal
• Normal LV size LV function is present ).

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Cardiac Measurements

 Cardiac Chamber Quantification

• Method: transthoracic, transesophageal, intra-cardiac

• Type: 2D, M-mode, Dolor Doppler, Tissue Doppler, 3D

• Function ; Systole, Diastole

ALPINION Medical Systems, Clinical SpecialistTeam

MP 1-5X SP 1-5/SP1-5 P 1-5CT

Pencil Type probe Pencil Type probe

ALPINION Medical Systems, Clinical SpecialistTeam

Transmit/Receive Receive Receive &Cut off : fₒ

cancel fundamental tissue signal

remain 2nd harmonic signal

ALPINION Medical Systems, Clinical SpecialistTeam

ALPINION Medical Systems, Clinical Specialist Team

ALPINION Medical Systems, Clinical SpecialistTeam

ALPINION Medical Systems , Clinical SpecialistTeam

Parameter Effect Parameter Effect

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ALPINION Medical Systems , Clinical SpecialistTeam

Color Power Doppler Pulsed wave Continuous wave

ALPINION Medical Systems , Clinical SpecialistTeam

ALPINION MedicalSystems, Clinical Specialist Team

ALPINION Medical Systems, Clinical Specialist Team

ALPINION Medical Systems, Clinical SpecialistTeam

ALPINION Medical Systems, Clinical SpecialistTeam

Zoom : contain the aortic valve and

2015 ASEGUIDELINES and STANDARDS

ALPINION Medical Systems, Clinical SpecialistTeam

ALPINION Medical Systems, Clinical Specialist Team

• Measure “ RV” dimension and

ALPINION Medical Systems, Clinical SpecialistTeam

ALPINION Medical Systems, Clinical SpecialistTeam

• Measure Ejection Fraction

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- RVD1 : maximal transverse dimension in the basal 1/3 of RV inflow

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• the circulation of blood in the blood vessels of the heart muscle

ALPINION Medical Systems, Clinical SpecialistTeam

ALPINION Medical Systems , Clinical SpecialistTeam

ALPINION Medical Systems, Clinical SpecialistTeam

ALPINION Medical Systems, Clinical SpecialistTeam

• Measure a diameter of the IVC

ALPINION Medical Systems, Clinical Specialist Team

• Incaseof Aorticregurgitation,tomeasurevelocityofthe DescendingAorta

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ALPINION Medical Systems, Clinical SpecialistTeam

ALPINION Medical Systems , Clinical SpecialistTeam

The Left Ventricle size and thickness

The LV Global Systolic Function

LV Regional Function LV Mass

The Right Ventricle

The Left and Right Atria

The Aortic Annulus and Aortic Root

ALPINION Medical Systems, Clinical SpecialistTeam

ALPINION Medical Systems, Clinical SpecialistTeam

• Different from system to system

ALPINION Medical Systems, Clinical SpecialistTeam

Left Ventricular function

Right Ventricular function