STANDARD PARASTERNAL TTE VIEWS STANDARD APICAL TTE VIEWS ASSESSMENT OF SYSTOLIC FUNCTION

BEFORE YOU START AN ECHOCARDIOGRAPHIC EXAMINATION:

Four Chamber Two Chamber Long Axis
Insert patient data.
Check for a stable ECG recording.

4-1
PX
Ask the patient to turn to a left lateral position. LV
RV AMVL

STANDARD EXAMINATION
PX4-1

4-1
PX
​ ptimize the image using total gain, time gain compensation and
O
depth. RA LA
Pay attention to dynamic range and frequency. Parasternal Subcostal Apical
Set machine to record three consecutive heart cycles
4-1

A4C
PX

probe position probe position probe position

1. Start with the parasternal long axis (PLAX). Record the mitral Aortic valve in PSAX
valve(MV), aortic valve(AV), septum and posterior wall. Base Mid Apex
The aorta should be visible from AV to ascending aorta. RCC
2. Record the MV and AV with color Doppler. When using color Doppler LCC LV
NCC
decrease the total gain. Note Nyquist limit and color gain. AMVL
3. Record MMode, perpundicular to the ventricular septum just Aorta level
below the tips of the MV leaflets for LV dimensions or measure 2D. Apical
PMVL
4. Rotate the probe 90 ° clockwise for the short axis (PSAX) and
RV LA
record on aortic level, then tilt the probe cranially for the MV, Scoring: 0: Not visualized
papillary muscles and apical levels. Record color Doppler in the LV PA
RA 1: Normokinesia 1
Mid papillary Papillary 4-1

pulmonic valve (PV), AV and tricuspid valve (TV).

PX

A2C 2: Hypokinesia 7

5. Record the apical 4 chamber (A4C). LA 3. Akinesia 2

8
13 12
6

6. Tilt the probe for the 5 chamber view with the aorta(A5C). 4. Dyskinesia 14 17 16
7. Rotate the probe counterclockwise to the 2 chamber view (A2C). 5. Aneurysmatic 11
9
8. Rotate the probe counterclockwise to the 3 chamber view (A3C) 3
15 5
Anterolateral papillary muscle
(same structures visible as PLAX). LV
10
Posteromedial papillary muscle 4
9. Record color Doppler in the MV and AV in the A3C, the MV in the A2C RV
and the MV, AV, TV in A4C and A5C. 1. basal anterior 7. mid anterior 13. apical anterior
2. basal anteroseptal 8. mid anteroseptal 14. apical septal
10. Record a pulsed wave (PW) doppler just at the tips of the MV SUBCOSTAL VIEW 3. basal inferoseptal 9. mid inferoseptal 15. apical inferior
leaflets for E/A ratio and record an PW tissue velocity imaging 4. basal inferior 10. mid inferior 16. apical lateral
4-1 LA 5. basal inferolateral 11. mid inferolateral 17. apex
signal(TVI) of the interventricular septum.
PX

6. basal anterolateral 12. mid anterolateral

11. Record a continuous wave (CW) in the AV and PW in LVOT. AO
Coronary Territory
12. Record a tricuspid annular plane systolic excursion (TAPSE) M-Mode through A3C
for right ventricular function. Inferior Caval Vein LAD: Segments 1, 7, 8, 9, 13, 14, 15, 16, 17
13. Record a subcostal view and the Inferior Caval Vein asking the patient RCX: Segments 5, 6, 11, 12
to sniff. 
 RCA: Segments 2, 3, 4, 10

  
14. Record a supraxyphoidal view for the ascending aorta, arch and


descending aorta.

If you have any comments please e-mail to Ivo van der Bilt: [email protected] This reference card is for education purposes only. When in doubt consult a Cardiologist. For more information: www.echopedia.org.

Echokaartje3.2.indd 1 24-08-14 23:53

 ASSESSMENT OF DIASTOLIC FUNCTION LEFT VENTRICULAR FUNCTION MITRAL VALVE REGURGITATION SEVERITY MITRAL VALVE STENOSIS WILKINS SCORE
LV function Normal Mild Moderate Severe Mild Moderate Severe Grade Mobility Leaflet Calcification Subvalvular
Mild Diastolic Moderate Diastolic Severe Diastolic Dysfunction
Normal Diastolic
Dysfunction
Thickening thickening
Function
Impaired Relaxation
Dysfunction Reversible Fixed
Ejection Fraction(%) >54 45-54 30-44 <30 Specific Small central jet <4 Signs of V. contracta ≥ 0.7cm,
Pseudonormal Restrictive Restrictive
Fractional Shortening cm2 or <20% of LA MR>mild central MR jet(area < 1 Mobile valve, only 4-5 mm Single aea minimal
0.75<E/A<1.5 E/A≤0.75 0.75<E/A<1.5 E/A>1.5 E/A>1.5 area2 present but 40% of LA) or with a wall- leaflet tip restricted
Endocardial(%) 25-45 20-26 15-21 ≤14
DT>140 ms DT>140 ms DT<140 ms DT<140 ms Vena contracta width no criteria for impinging jet, swirling
2.0
Midwall(%) 12-23 12-14 10-12 ≤10
Velocity, m/s

E <0.3 cm severe MR in LA2. 2 Leaflet mid and 5-8 mm, Scattered Extending 1/3 of
Mitral Inflow
A No or minimal flow Large flow convergence5 basal normal midleaflet areas chordal length
RIGHT VENTRICULAR FUNCTION convergence Syst. pulm. vein reversal normal
0 Adur
RV function Normal Mild Moderate Severe
Supportive Systolic dominant Intermediate Dense, triangular CW 3 Valve continues 5-8 mm, Calcium ex- Extending to
ΔE/A<0.5 ΔE/A<0.5 ΔE/A≥0.5 ΔE/A≥0.5 ΔE/A<0.5 RV diastolic area, cm2 11-28 29-32 33-37 ≥38 flow in pulmonary signs/findings Doppler MR jet to move forward extending tending into distal third of chords
2.0
veins E-wave dominant mitral
Velocity, m/s

Mitral Inflow at RV systolic area, cm2 7.5-16 17-19 20-22 ≥23 in diastole, mainly through en- mid portion
Peak Valsalva E A-wave dominant inflow (E >1.2m/s)4. from the base tire leaflet of leaflet
A fractional area change 32-60 25-31 18-24 ≤17 mitral inflow4 Dilated LV/LA3.
Maneuver
0 TAPSE (cm) 1.5-2.0 1.3-1.5 1.0-1.2 <1.0 Soft density, para- 4 No or minimal >8-10 mm Extensive Extensive, extending
bolic CW Doppler MR forward movement throughout to papillary muscle
AORTIC VALVE STENOSIS SEVERITY
Velocity, m/s

Doppler Tissue 0
E/e'<10 E/e'<10 E/e'≥10 E/e'≥10 E/e'≥10 signal of the leaflets in most of the
Normal LV size1 diastole leaflet
Imaging of Mitral
0.15 e'
a' Sclerosis Mild Moderate Severe
Annular Motion

Aortic jet velocity(m/s) ≤2.5 2.6-2.9 3.0-4.0 >4 Quantitave6 REFERENCE VALUES
S≥D S>D S<D or S<D or S<D or EROA(cm2) <0.20 0.2-0.29/0.3-0.4 ≥0.40
ARdur>Adur+30 ms ARdur>Adur+30 ms ARdur>Adur+30 ms Mean gradient (mmHg) - >20 20-40 >40
2.0
ARdur<Adur ARdur<Adur
RF (%) <30 30-39/40-49 ≥50
AVA(cm2) - >1.5 1.0-1.5 <1 Normal Normal
Velocity, m/s

R vol (ml) <30 30-44/45-59 ≥60

Pulmonary
S D AVI=AVA/BSA(cm2/m2) - >0.85 0.6-0.85 <0.6 Ejection Fraction(%) >54 LVOT(cm) 1.8-2.4
ARdur
Venous Flow LV mass/BSA(g/m2) 43-95 RVOT(above AV)(cm) 2.5-2.9
0
AR
Time, ms Time, ms Time, ms Time, ms Time, ms
AORTIC VALVE REGURGITATION SEVERITY MITRAL VALVE STENOSIS SEVERITY Septal thickness(mm) <12 TAPSE(cm) 1.5-2.0
Posterior wall thickness(mm) 0.6-1.0 LA volume/BSA(ml/m2) 22 ±6
Left Ventricular Relaxation Normal Impaired Impaired Impaired Impaired Mild Moderate Severe Mild Moderate Severe LV diast. vol/BSA(ml/m2) 35-86 LA diameter/BSA(cm/m2) 1.5-2.3
Left Ventricular Compliance Normal Normal to ↓ ↓↓ ↓↓↓ ↓↓↓↓
Atrial Pressure Normal Normal ↑↑ ↑↑↑ ↑↑↑↑ Specific Central Jet, width>25% Signs of Central Jet, width ≥ LV syst. vol/BSA(ml/m2) 12-30 RA diameter/BSA(cm/m2) 1.7-2.5
Specific >1.5 1.0-1.5 <1.0 LVEDD(cm) 3.9-5.9 Ascending aorta diam
LVOT2 AR>mild 65% of LVOT2 Valve area(cm2)
Vena contracta <0.3 cm2 present but Vena contracta > LV diast. volume/BSA(ml/m2) 35-75 (normal/Marfan (mm)) <50/<45
Septal e’ LV syst. volume/BSA(ml/m2) 12-30
No/brief early diastolic no criteria for 0.6cm2 Supportive
Lateral e’ flow reversal in descending severe AR Mean gradient(mmHg) <5 5-10 >10
LA volume aorta Pulmonary artery
AVA, Aortic valve area; AR, Aortic regurgitation; EROA, effective regurgitant orifice area;
LV, left ventricle; L(R)VOT, left(right) ventricular outflow tract; R Vol, regurgitant volume;
pressure(mmHg) <30 30-50 >50
Septal e’ ≥ 8 Septal e’ ≥ 8 Septal e’ < 8 Supportive Pressure half time > 500 ms Intermediate Pressure half-time < RF, regurgitant fraction; LVEDD, LV end diastolic diameter; TAPSE, tricuspid annular
Lateral e’ ≥ 10 Lateral e’ ≥ 10 Lateral e’ < 10 Normal LV size1 values 200 ms plane systolic excursion; LA, left atrium; RA Right atrium; BSA, Body Surface Area. CW,
LA < 34 ml/m2 LA ≥ 34 ml/m2 LA ≥ 34 ml/m2 Holodiastolic aortic Aortic arch Continuous wave.
Tubular ascending aorta 22 - 36 mm 1
LV size applied only to chronic lesions.
flow reversal in de-
E/A < 0.8 E/A 0.8-1.5 E/A ≥ 2 22 - 36 mm
scending aorta 2
2
At a Nyquist limit of 50–60 cm/s.
(15±2 mm/m )

Ascending aorta
DT > 200 ms DT 160-200 ms DT < 160 ms 3
In the absence of other etiologies of LV dilatation.
Moderate or greater PA
Av. E/e’ ≤ 8 Av. E/e’ 9-12 Av. E/e’ ≥ 13 Sinotubular junction 4
Usually above 50 years of age or in conditions of impaired relaxation, without elevated
LV enlargement3
Ar-A < 0 ms Ar-A ≥ 30 ms Ar-A ≥ 30 ms 22 - 36 mm
Quantitave$ Descending aorta LA pressure(MS).
Val ΔE/A < 0.5 Val ΔE/A ≥ 0.5 Val ΔE/A ≥ 0.5 (15±1 mm/m )
2
20 - 30 mm
EROA$ <0.10 0.10-0.19 ≥0.30 5
Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and
Normal. Normal function, RF (%) <30 30-39/40-49 ≥50 Sinuses of Valsalva ≤ 0.9 cm for central jets, respectively, with a baseline shift at a Nyquist of 40 cm/s; Cut-offs
function Athlete’s heart, or Grade I Grade II Grade III R vol (ml/ <30 30-44/45-59 ≥60 29 - 45 mm Aortic a nnulus for eccentric jets are higher, and should be angle corrected (see text).
2
beat) (19±1 mm/m ) 20 - 31 mm 6
Quantitative parameters can help sub-classify the moderate regurgitation group into
constriction 2
(13±1 mm/mm ) mild-to-moderate and moderate-to-severe as shown.

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