Echocardiography Protocol Guide Contents

Adult Stress Echocardiography Protocol....................................................................................................... 2

Contrast Echocardiography Protocol ............................................................................................................ 7
Transesophageal Echocardiography ............................................................................................................. 8
Transthorax Echocardiography ................................................................................................................... 16
Adult Stress Echocardiography Protocol
The purpose of this protocol is to provide standardized directions for conducting an exercise
echocardiography study.

Patient Assessment
 Patient history reviewed
 Ensure correct test type
 Check lab test results
 Identify possible contraindications to the test and discuss history with the physician

Contraindications to the test:

 Unstable angina
 Acute myocardial infarction
 Serious ventricular or supraventicular arrhythmias
 Serious hypertension at rest (systolic >200 mm Hg: diastolic >100 mm Hg)
 Severe valvular heart disease
 Hypertrophic cardiomyopathy
 Significant hypotension at rest (systolic blood pressure < 90 mm Hg)
 Moderately severe or severe aortic stenosis in the presence of symptoms

Additional contraindications that require a mandatory consultation with a physician before

initiating the test.
 Borderline hypotension: systolic blood pressure between 90 mm Hg and 100 mm Hg
 Severe LV dysfunction with LVEF<35%
 Severe aortic stenosis (AVA ≤ 1 cm2) in an asymptomatic patient
 Lack of documentation of a recent visit with a physician > 3 months
 Recent myocardial infarction < 2 weeks
 Presence of ST elevation in the resting ECG
 Patient is unable to consent, unless specifically stated in the chart that a family member
has provided consent for the test. In most cases if the patient is confused, disoriented or
with other obvious mental status changes the test should be canceled.
 Presence of frequent ventricular arrhythmia in the resting ECG
 Rapid atrial fibrillation, ventricular response ≥ 80% PMH
 Any unexpected significant findings: tumors of the heart, aortic dissection, severe
pulmonary hypertension, large pericardial effusions, etc.
 Positive troponin or less than 2 negative sets of cardiac enzymes (minimum of 4 hours
apart, normal value of ≤0.04)

Procedure Preparation

 Provide changing instructions to the patient

 Confirmation of patient's NPO status
 Enter the patient name and other information in the echo machine and, ECG stress system
 Explain the test to the patient and answer patient’s questions.
 Determine medical history/allergies/medications.
  Check lab information, particularly for inpatients and ER patients to rule out contraindications
 Consult the physician if a patient has chest pain prior to exercise
 Consult physician if patient's history suggests unstable angina event if troponin is in normal
ranges

Patient Preparation

 Shave hair from electrodes sites if necessary

 Vigorously rub each electrode site with alcohol and a clean washcloth
 Completely dry the skin surface
 Abrade the skin surface at each site with skin prep strip. (Explain the reason for this procedure
to the patient.) Remember it may be necessary to modify the 12-lead hook-up to allow room for
the ultrasound transducer.
 Make sure there is a staff physician in the echo lab

Pre-exercise

Perform hook up for 12 lead ECG monitoring

 Strap cable belt around the patient and ensure comfort to the patient
 Attach lead wire to appropriate electrode sites
 Check leads for artifact
Obtain resting ECG, HR and BP

 Obtain supine resting ECG. This should be free of artifact

 Obtain resting BP. Inform the fellow/attending if the resting BP is elevated (200/100 mm Hg).
Obtain resting TTE

 Resting echo is performed with patient placed in the lateral decubitus position. Images are
recorded digitally.

Resting Digital Protocol Images

1. The five standard views that are acquired are: parasternal long axis, parasternal short
axis, apical 4-chamber and apical 2-chamber. Apical long-axis view may be added.
2. If the standard views are not obtainable, due to body habitus or image quality, other views such
as the subcostal 4-chamber or short axis may be substituted.

3. If the images are too poor, the test may be canceled after discussion with the stress echo
reader. If the images are poor, echo contrast should be used. If there are contraindications to
the contrast agent, the test may be canceled after discussing with the stress echo reader.

4. Sonographer should inform abnormal findings to the exercise physiologist, fellow or echo
attending before exercise. Communication of echo findings between the sonographer and the
exercise physiologist is required before, during and post exercise.

5. The abnormal findings on resting ECG and resting echo should be discussed with the fellow or
echo faculty, obtaining an approval before starting the test.
Exercise the patient

1. Provide patient instruction

2. Demonstrate the technique for walking on a treadmill
3. Instruct the patient on the use of the 10 point Borg RPE scale
4. The exercise should begin when the patient feels comfortable on the treadmill
5. Decisions regarding exercise protocol should be made by the physician or exercise
physiologist; choose the right protocol for the patient.
6. Obtain a BP prior to the end of each stage.
7. Provide encouragement and motivation toward obtaining maximal exercise capacity
8. The patient should be the main focus. The sonographer should remain standing at the
side of the treadmill in the event the patient requires assistance
9. Timing of the end of the test should be coordinated between the sonographer and the
physician or exercise physiologist. The patient should be directed back to the table.

10 Point Borg RPE Scale Instructions to Patient

To rate your perception of exertion when you exercise, don't focus on just one sensation. Get a general
sense of how hard you are exercising. Use your feelings of exertion rather than measures such as speed
while running or cycling or comparing yourself to someone else. Then assign your exertion a number
from 6 to 10 on the Borg Rating of Perceived Exertion scale.

The scale starts at 6, which means you feel no exertion, similar to simply standing still. Level 2-3
is light activity feels like you can maintain for hours. Easy to breath and talk. At 4-6 you are in
the moderate activity where breathing is heavy, can hold short conversation and still somewhat
comfortable but is more challenging. At level 7 to 8 you are in the vigorous activity zone and it
feels borderline uncomfortable, short of breath, can speak a short sentence. At level 9 the
activity is very hard and difficult to maintain exercise intensity. Can only speak a few words. At
level 10 you feel it is almost impossible to keep going. Completely out of breath, unable to talk.
Cannot maintain for more than a very short time.

Post exercise Images

1. The post exercise images should be done quickly in one minute or less as possible. 90 seconds is
considered the time limit to acquire the post images. The same images are acquired as pre-
exercise. The five standard views that are acquired are: parasternal long axis, parasternal short
axis, apical 4-chamber and apical 2-chamber. Apical long-axis view may be added.
2. The test is considered less diagnostic for ischemia after two minutes and if the images are
obtained after this point, it should be documented and inform the stress echo reader by
sonographer.
3. If the patient has symptoms, positive ECG change or new regional wall motion abnormality post
exercise, additional echo image should be obtained during recovery.
4. Obtain a post exercise BP.
Recovery of the patient

A. Monitor the patient until ECG, symptoms and arrhythmias are resolved and the blood pressure
and heart rate have normalized to baseline.
 B. It is mandatory to consults with the stress echo reading physician after the test is terminated
before the patient leaves the area with the following:
1. There is ST elevation in the stress ECG
2. Persistent hypotension
3. Chest pain during and after the stress test.
4. Any new sustained SV arrhythmia, i.e. atrial fibrillation, flutter or SVT
5. Any ventricular tachycardia > 4 beats, especially if occurs in recovery
6. Persistent ST depression after termination of the test
7. If the sonographer thinks that the echo shows evidence of ischemia and exercise
induced-wall motion abnormality.
8. Other severe side effects.

Post Procedure

 Upon completion of the peak images, store them to the hard drive and then transfer them to the
server
 Obtain post exercise BP and monitor patient during recovery
 Unhook the patient and remove the electrodes and wipe off the gel
 Provide the patient with juice, water, towels, etc. as needed.
 Route the patient appropriately and escort to desk or waiting room
 Digital image will be transferred to the PACS server and ECG data will be transferred to the
system.

Patients Discharge

Exercise physiologist or sonographer should consult the physician before releasing patients if the
following conditions are encountered.

 Chest pain during exercise

 Positive ECG changes
 Severe arrhythmias: atrial fibrillation, ventricular tachycardia, persistent SVT.
 Severe hypertension after recovery (BP >180/100 mmHg)
 Hypotension after recovery (SBP <90 mmHg)
 Significant new wall motion abnormality
 Patient feel ill

Reporting
1. The stress ECG portion of the test should be entered into the stress database at the time
of the exam and at the end of the test.
2. The echo portion of the exam (the digitized images) is reviewed by the echo attending
along with the stress ECG portion.

Other Clinician’s Roles in Stress Echo Laboratory

Nurse’s Role may be to

1. Start IV for echo contrast, bubble study (if needed)
2. Give definite echo contrast, and medications as directed by physician or cardiology fellow
 3. Report clinical symptoms and abnormal finding to exercise physiologist and physicians
4. Check and ensure resuscitation equipment and medications in appreciate position and
functioning normally
5. Help physician to manage unstable patients
Exercise Physiologist’s / Nurse Practitioner’s Role may be to

1. Screening and interviewing patients and provide explanation of stress test to patients
2. Taking history and reviewing laboratory data, identifying high risk patients and
contraindications.
3. Set exercise stress protocol and monitor the conduction of exercise
4. Enter exercise test data into computer
5. Collection of ECG and echo tape, handle them over to physicians
6. Report abnormal symptoms and abnormal ECG findings to physicians

Equipment Maintenance

Defibrillator and code cart checked daily and documented on checklist.

Contrast Echocardiography Protocol
Microbubble ultrasound enhancement agents (UEA/Contrast) are used to improve the
diagnostic quality in technically difficult exams. There are two categories of contrast: agitated
saline and pharmaceutical microbubble agents. Agitated saline contrast is used to identify
intracardiac and extracardiac shunts.

Indications and Scheduling:

 If the sonographer identifies a need for UEA echocardiography IV access will be
established. If the patient does not already have IV access, IV access can be obtained by
a nurse or qualified sonographer or nuclear medicine technologist.
 If a patient is only needing UEA exam then they are usually scheduled for a limited
exam.

Special Equipment:
 IV Access.
 10 ml prefilled saline syringes
 Commercially available UEAS approved by the FDA: (1) Lumason, (2) Definity, (3)
Optison
 Three-way stopcock (if applicable), 10ml syringe (if applicable), needles. Syringe pump
if needed.

Pre-procedure:
 Contrast order by physician or standing order
 Informed consent
 Patient education

Technical Criteria:
 Appropriate equipment settings or preset
 Mechanical Index <0.3 for optimal detection
 Lowest frequency for optimal detection and to avoid greater destruction of contrast
 If rate or dosing of administration is too fast, will have attenuation
 If rate or dosing of administration is too low, will have swirling
 If dosing concentration is too high, will have attenuation

Agitated Saline Contrast Protocol

 An IV is started in a peripheral vein by the nurse or qualified sonographer.

 Cardiac structures are identified on the echo monitor with a recording made by the
sonographer.
 There are 2 possible options for agitated saline contrast. The option used is based on the
clinical site’s protocol.
o Option 1: ~8-9 ml of Sodium Chloride is mixed with a small amount of the
patient’s blood that has been drawn from the IV site and minimal air if needed.
The blood and saline are then rapidly agitated through a three-way stopcock.
When there is adequate mixing the stopcock is opened to the patient and the saline
is rapidly injected.
 o Option 2: ~8-9 ml of Sodium Chloride is mixed with minimal air if needed. The
saline and air are then rapidly agitated through a three-way stopcock. When there
is adequate mixing the stopcock is opened to the patient and the saline is rapidly
injected.
 The sonographer will record continuously before, during, and after injection.
 Repeat if necessary.
 The IV is discontinued.

Pharmaceutical Microbubble Contrast Protocol

 Pharmaceutical Microbubble UEA will be administered following the manufacturer’s

recommendations and/or the American Society of Echocardiography guidelines and
Medical Director suggestions of the clinical site.
 The patient will have an IV started by the nurse or the qualified sonographer.
 The sonographer will evaluate the patient for possible contraindications.
 The sonographer will obtain the images using correct preset and imaging parameters for
UEA echocardiography.
 The sonographer or other qualified staff will administer UEA using the clinical site’s
protocol.
o Bolus – inject UEA using manufacturers recommendations. 2 ml bolus followed
by saline flush. Repeat if necessary.
o Diluted bolus
 Use 10 ml prefilled saline syringe in place of manufacturers 5 ml syringe.
 Inject 5 ml from prefilled syringe into vial leaving 5 ml saline in syringe.
 Shake well until product is completely dissolved.
 Draw back into 10 ml syringe creating 10 ml diluted bolus.
 Inject 1-3 mL followed by saline flush
 Repeat if necessary.
o 50 mL diluted infusion.
 Dilute product with saline in 50 ml syringe.
 Infuse at a rate of 1-5 ml/minute with syringe pump to achieve desired
imaging effect.
 Adjust rate if needed.
 The sonographer will optimize the image and obtain loops according to imaging protocol.
 Any evidence of adverse reactions will be reported as appropriate to the director of the
cardiopulmonary lab in order that it can be documented.

Reporting
 The UEA echo report will be added to the echocardiogram report and will be processed
in the same manner as the echocardiogram report.
The purpose of this protocol is to provide assisting sonographers standardized directions for
participating in a TEE study.

Transesophageal Echocardiography
Patient Assessment
  Patient history reviewed
 Ensure correct test type
 Check lab test results
 Identify possible contraindications to the test and discuss history with the physician

Indications for TEE

 Evaluation of cardiac and aortic structure and function in situations where the findings will alter
management and TTE is nondiagnostic or TTE is deferred because there is a high probability that
it will be non-diagnostic.
 Intraoperative TEE
 Guidance of transcatheter procedures
 Critically ill patients

Appropriate Use Criteria for TEE as initial or supplemental exam

 Use of TEE when there is a high likelihood of a nondiagnostic TTE due to patient characteristics
or inadequate visualization of relevant structures.
 Re-evaluation of prior TEE finding for interval change (e.g., resolution of thrombus after
anticoagulation, resolution of vegetation after antibiotic therapy) when a change in therapy is
anticipated.
 Guidance during percutaneous noncoronary cardiac interventions including, but not limited to,
closure device placement, radiofrequency ablation, and percutaneous valve procedures.
 Suspected acute aortic pathology including but not limited to dissection/transection.
 Evaluation of valvular structure and function to assess suitability for, and assist in planning of, an
intervention.
 To diagnose infective endocarditis with a moderate or high pretest probability (e.g., staph
bacteremia, fungemia, prosthetic heart valve, or intracardiac device).
 Evaluation for cardiovascular source of embolus with no identified noncardiac source.
 Atrial fibrillation/flutter: evaluation to facilitate clinical decision making with regard to
anticoagulation, cardioversion, and/or radiofrequency ablation.

Absolute Contraindications to the test:

 Perforated viscus
 Esophageal stricture
 Esophageal tumor
 Esophageal perforation, laceration
 Esophageal diverticulum
 Active upper GI bleed

Relative Contraindications to the test:

 History of radiation to neck and mediastinum
 History of GI surgery
 Recent upper GI bleed
 Barrett’s esophagus
 History of dysphagia
 Restriction of neck mobility (severe cervical arthritis, atlantoaxial joint disease)
 Symptomatic hiatal hernia
 Esophageal varices
 Coagulopathy, thrombocytopenia
  Active esophagitis
 Active peptic ulcer disease

Moderate Sedation

 NPO for minimum of 6 hours , longer if delayed gastric emptying and other aspiration risks
 Medications may be taken on schedule with a small sip of water
 IV access with a 20-gauge catheter is required and the left arm is recommended to facilitate
contrast injections as needed. Right arm may be preferred when the patient is in the LLD
position.
 Room must be equipped with an oxygen source and suction devices.
 Airway equipment (endotracheal tubes and laryngoscopes) in case of respiratory failure and
emergency medications for Advanced Cardiovascular Life Support protocol should be easily
accessible.
 Physician calculates a modified Aldrete score. Conscious sedation defined as a score of 9 or 10,
with a score of <9 defining oversedation.
 Monitor heart rate, blood pressure, respiratory rate and oxygen saturation during conscious
sedation
 Awake patients receive oropharynx anesthetized with topical administration of a local
anesthetic before administration of benzodiazepine therapy
 Opioids can be used as adjuncts to the procedure to offset the discomfort of probe insertion.
 Intravenous reversal agents are available for benzodiazepine (flumazenil) and opioids (naloxone)

Probe Insertion Techniques

 After adequate application of topical anesthetic, bite block should be placed in the patient’s
mouth before the administration of conscious sedation
 With the patient in the LLD position, the physician stands facing the patient. The probe is
checked for any obvious damage. Then the probe is inserted to the back of the pharynx and the
patient is asked to swallow. As the patient swallows the probe is advanced in a neutral position
down the esophagus.

Instrument Controls
Comprehensive Exam Images (28 Views)
Post Procedure Monitoring and Discharge

 The patient must be monitory following the procedure to assure that no complications have
arisen either from the proedure or the medication admistered.
 The patient and/or the family must be instructed on any post-procedure care that the physican
feels is necessary.
 Information must be given to outpatients that will allow them to contact the performing
physican or physican on call should complications arise after patient discharge.
Transthorax Echocardiography
I. Getting Started
A. Check for previous studies and review key elements.
B. Optimize instrument settings prior to starting study.
C. Verify indication for exam.
D. Review order and understand physician’s request. You must have an order to perform the
exam.
II. Procedure Preparation
A. Review the order for type of study to be performed. A verbal order may be used for stat
echocardiography and written order will be obtained as soon as possible.
B. Enter patient information into ultrasound system (from pick list or manually).
C. Enter demographics, height, weight, BP, sonographer’s name, all other information as needed.
III. Patient Preparation
A. Explain procedure to patient.
B. Verify patient ID.
C. Instruct patient to lie on left side.
D. Apply electrodes and attach leads.
E. For subcostal view have the patient lay on their back and bend their knees to soften the
abdominal muscles.
F. For suprasternal notch view have the patient lay on their back with a pillow under their
shoulders to allow for the probe to be rotated correctly
IV. Digital Capture
A. Make sure that you have adequate ECG signal.
B. Patients in sinus rhythm, 2 beat captures are used.
C. Patients in A-fib or any irregular rhythm, 3-5 beat captures should be used as needed.
D. When capturing a bubble contrast study use 5-10 second loops.

If images are suboptimal (greater than or equal to two adjacent segments in an apical view) and primary
question is LV function and wall motion, consider use of an echo contrast agent (trans-pulmonic agent)
after discussion with Cardiologist or Attending.

Basic Exam (note: obtain a 2D image of the view first, followed by color/spectral Doppler in order to
provide anatomic orientation). In general, spectral Doppler and M-mode should be captured at a sweep
speed of 50 mm/s speed. Use 25-50 mm/s speed to demonstrate respire-phasic changes that require
documentation of changes across several cardiac cycles and 100 mm/s speed when making timing
measurements. The information recommended here is a basic standard and may vary from clinical site
to clinical site.

Optimization of Doppler signals. Doppler display occupies about 2/3 of scale for each velocity.
Pay particular attention to:
 Narrow aiming sector to optimize color and frame rate.
 If 2D imaging is poor (esp. in apical views) or two or more LV segments are unable to be
assessed, contrast may be considered to enhance the image.
  Proper setting of the scale, gain, filter, compress and reject with CW & PW Doppler.
 Look at extra-cardiac structures.
 Use off-axis images when necessary.
 Spectral Doppler - The angle of incidence should be less than 20° and obtain 3 consecutive
waveforms, measuring the middle waveform
 Continuous wave Doppler - Perform continuous wave Doppler tracing on all valves with a
velocity greater than 2m/sec. For the mitral valve, include the pressure ½ time. Perform
continuous wave Doppler tracing on all valve replacements and repairs

IMAGING PROTOCOL

I. Parasternal Long-Axis View Overview

A. Rule out pericardial/pleural effusion and assess extracardiac structures by increasing and
decreasing depth. Capture 2D view. Zoom aortic and mitral valve and capture a 2D view.
B. Measure LV septal thickness, LV end-diastolic dimension and posterior wall thickness in end-
diastole at the level of the mitral valve chordae.
C. Measure LV end-systolic dimension in end systole at the level of the mitral valve chordae.
D. Measure ascending aorta (routinely measured by 2D at level of the sinus). The additional
measurements of the diameters of aortic annulus, sino-tubular junction and mid ascending
aorta are needed when abnormal aorta is suspected. A separate ascending aorta image may
be required.
E. Measure the LA dimension in end-systole.
F. Perform color Doppler of AV/MV/Ventricular septum (requires separate captures). AV and MV
with zoom and color Doppler as needed.
G. A right ventricular outflow view may be obtained as clinically needed (congenital heart
disease).

Parasternal Window from the Long Axis Scan Plane

Structure Image Stored

Left Ventricle Acquire cine loop 2D image at a depth of 15-20cm

Left Ventricle Acquire cine loop 2D image at a reduced depth so image fills field of view

Aortic Valve M-mode sweep of aortic valve (sweep speed at 50-66mm/min) freeze and acquire

Mitral Valve M-mode sweep of mitral valve (sweep speed at 50-66mm/min) freeze and acquire

Left Ventricle M-mode sweep of left ventricle (sweep speed at 50-66mm/min) freeze and acquire

Left Ventricle Freeze 2D image of left ventricle without papillary muscles and AV closure in the center of
the aorta, both aortic and mitral valve in the maximal excursion:
Scroll back to end diastole (mitral valve closure or QRS) and measure the following:
 Interventricular Septum in diastole (IVSd)
 Measure the vertical distance from the RV side of the IVS to the LV side of
the IVS at end-diastole.
  Normal range is 0.6 – 1.2cm
 LV minor axis end-diastole (LVIDd) also called LVEDD
 Measure the vertical distance from the endocardium of the IVS to the
endocardium of the LVPW at end-diastole.
 Normal range is 3.5 – 5.6 cm.
 LV Posterior Wall Diastolic Thickness (LVPWd) = Measure the vertical distance from
the endocardium of the LVPW to the epicardium at end-diastole.
Normal range is 0.6 – 1.2cm
 RV diameter end-diastole (RVIDd)
 Measure the vertical distance from the endocardium of the IVS to the
endocardium of the right ventricular free wall at the end of diastole
 Acquire still frame DO NOT UNFREEZE THE IMAGE!
Left Ventricle From the previous frozen image, scroll forward to end systole (one beat before the valve
opens or end of T wave) and measure the following:
 LV minor axis end-systole (LVIDs) also called LVESD
 Measure the vertical distance from the endocardium of the IVS to the
endocardium of the PWLV at end-systole.
 Normal range is 2.0-4.0 cm.
 LA end-systole (LAs)
 Measure the LA at the aortic valve plane, posterior to anterior
measurement. Caliper placement is leading edge of posterior wall of the
aorta to the leading edge of the posterior wall of the LA. Acquire still frame.
 Normal range is 2.3 – 3.8 cm.
Aortic Valve Zoomed. Acquire cine loop 2D image

Aortic Valve Zoomed. Freeze 2D image of aortic valve. Scroll back to end diastole (mitral valve closure or
Sinus of QRS)
Valsalva  Measure AV sinus of Valsalva diameter with the valve plane perpendicular to the
wall of the aortic root. Measure leading edge to leading edge.
 Normal range 2.1 – 3.5 cm
Aortic Valve Zoomed. Freeze 2D image of aortic valve. Scroll back to mid systole
Annular  Measure AV annular diameter (HINT: on the ventricle side of the valve) with the
Diameter valve plane perpendicular to the wall of the aortic root. Measure inner edge to
inner edge.
 Acquire still frame w/measurement DO NOT UNFREEZE THE IMAGE!
Aortic Valve Zoomed. Do not unfreeze the image from the previous frozen image at mid systole
LVOT Diameter  Measure left ventricular outflow track diameter (LVOT) from the base of the aortic
valve leaflets (HINT: on the ventricle side of the valve – slightly more towards the
ventricle than the AV annular diameter). Measure inner edge to inner edge
 Normal measurement 2.0 cm
 Acquire still frame w/measurement
Mitral Valve Zoomed. Acquire cine loop of 2D image of mitral valve

AV & MV Un-zoomed. Acquire cine loop of Color Doppler across both mitral valve & aortic valve

Helpful Tip: Caliper placement for measurements taken on the ventricle side of the aortic valve should
be inner edge to inner edge. Caliper placement for measurements take on the aorta side of the aortic
valve should be leading edge to leading edge.
II. RV Inflow View Overview
A. Capture 2D image.
B. Perform color Doppler of TV for TR.
C. Measure peak TR velocity for calculation of RA/RV pressure gradient.

Parasternal Window from the Long Axis Scan Plane

Structure Image Stored

RVIT Right ventricular inflow track (RVIT)

Acquire cine loop of 2D image of right ventricular inflow track (RVIT)
RVIT Acquire cine loop of color Doppler across the tricuspid valve(TV)

RVIT Acquire continuous wave Doppler across the tricuspid valve with measurement IF
tricuspid regurgitation present

III. Parasternal Short-Axis View (Aortic Level) Overview

A. Capture 2D image at the level of the AV (imaging AV, TV, PV and LA), examine AV, PV and TV
leaflets, structures with 2D, PW, CW and color Doppler.
B. Aortic valve level:
1. 2D image.
2. Zoom aortic valve.
3. Perform color Doppler on the AV.
4. Perform color Doppler on the PV and PA.
5. Perform PW and CW Doppler across the PV.
6. Perform CW Doppler to obtain TR velocity to calculate PASP if TR is present.

IV. Parasternal Short-Axis (Left ventricle) Overview

A. Capture 2D LV at basal, middle (papillary muscle) and apex levels.
B. Zoom the LV at the MV leaflet level and perform color Doppler in the presence of MVdisease
as needed.

Parasternal Window from the Short Axis Scan Plane

Structure Image Stored

AV, TV, PV Acquire cine loop of 2D image of aortic valve, tricuspid valve, and pulmonary valve

PV Acquire cine loop of color Doppler across the Pulmonary artery/valve

PV Acquire pulse wave at pulmonary leaflet tips. Normal range 0.6-1.0 m/s

PV Acquire continuous wave through pulmonary valve for pulmonary valve flow and
pulmonary insufficiency with measurement of PI if present.
 Aortic Valve Acquire cine loop of 2D image of the aortic valve
Zoomed
Aortic Valve Acquire cine loop of color Doppler across the aortic valve& atrial septal wall
not Zoomed
Tricuspid Valve Acquire cine loop of color Doppler across the tricuspid valve for tricuspid
regurgitation
LV & MV Acquire cine loop of 2D image of left ventricle at level of the mitral valve

LV & MV Acquire cine loop of color Doppler of left ventricle at level of the mitral valve across
the septal wall & mitral valve
LV & Papillary Acquire cine loop of 2D image of left ventricle at level of the papillary muscles
Apex of LV Acquire cine loop of 2D image of left ventricle apex

V. Apical 4-Chamber View Overview

A. Capture 2D image to examine the structure and wall motion; avoid foreshortening of the LV.
Use a narrow 2D sector and/or zoom to improve image quality to assess LV wall motion and
look for a thrombus. Adjust depth, focal point, probe setting (frequency) and gains to optimize
images.
B. Perform color Doppler of MV, TV and AV.
C. Perform PW Doppler of the MV with the sample volume at the leaflet tips, measure E/A waves
velocities.
D. Perform tissue Doppler of lateral and septal mitral annulus to measure E’, for E/E’ ratio as
needed.
E. Perform Color M-mode Doppler as needed.
F. Perform CW of MV, TV.
G. LV volumes are measured in diastole and systole to obtain an ejection fraction. During tracing,
pay particular attention to: apical foreshortening; including (not excluding) papillary muscle in
tracing; apical alignment; mitral annulus. If calculated EF is significantly discordant with visual
estimate, review, acquire and measure additional cardiac cycles.
H. Each of the above measurements will be frozen and then acquired.
I. Measure LA and RA areas as needed.
J. Perform PW Doppler of pulmonary veins (sample volume 3-4 mm) as needed.

Apical Window 4 Chamber Scan Plane

Structure Image Stored

4 Chamber Acquire cine loop of 2D image showing all 4 chambers

4 Chamber Acquire cine loop of color Doppler of flow across mitral valve & left atrium for
Mitral valve mitral regurgitation
4 Chamber Acquire pulse wave Doppler at the tips of the mitral valve leaflets and freeze
Mitral valve image:
 Measure E to A & descending slope
  Acquire image with measurement
4 Chamber Acquire continuous wave Doppler across mitral valve and freeze image:
Mitral valve
4 Chamber Left Acquire an apical 4 chamber image and freeze image
Atrium  Trace LA volume in 4 chamber at the end of systole
 Acquire image with measurement
4 Chamber Acquire 2D image with a decreased depth demonstrating the left ventricle and 1/3
Left Ventricle & of the left atrium
Left Atrium
4 Chamber Acquire cine loop tissue Doppler imaging (TDI) of left ventricle and 1/3 of the left
Left Ventricle & atrium: Place pulsed Doppler cursor at the lateral aspect of the MV annulus:
Left Atrium  Measure E prime
 Acquire image with measurement
4 Chamber Acquire pulse wave Doppler 1-2 cm within the pulmonary vein and freeze image:
Pulmonary  Documenting the systolic and diastolic forward flow – used to determine
Veins diastolic function
4 Chamber Acquire 2D cine loop of the tricuspid valve
Tricuspid Valve
4 Chamber Acquire cine loop of color Doppler across the tricuspid valve
Tricuspid Valve
4 Chamber Acquire continuous wave Doppler across the tricuspid valve IF tricuspid
Tricuspid Valve regurgitation:
 Measure tricuspid regurgitation
 Acquire image with measurement
4 Chamber Acquire m-mode tracing of the TV annulus
Tricuspid Valve  Measure the tricuspid annular plane systolic excursion (TAPSE) from the
minimum to maximum excursion. Measure leading edge of the annulus
from the end-diastole toward the apex at end-systole
 Acquire image with measurement
4 Chamber Acquire an apical 4 chamber image and freeze image
Right Atrium  Trace RA volume in 4 chamber at the end of systole
 Acquire image with measurement
4 Chamber *Biplane Simpson’s Method:
Right Ventricle  Acquire an apical 4 chamber image and freeze
 Scroll to end-diastole and trace the LV cavity and store image
 Measure the length of the LVED from the mid mitral annulus to the cardiac
apex and store image
 This will give you the LV ED volume DO NOT UNFREEZE THE IMAGE
 Scroll to end-systole and trace the LV cavity and store image
 Measure the length of the LVED from the mid mitral annulus to the cardiac
apex and store image
 This will give you the LV ES volume
4 Chamber Acquire cine loop tissue Doppler imaging (TDI) of right ventricle and 1/3 of the left
Right Ventricle atrium: Place pulsed Doppler cursor at the lateral aspect of the TV annulus:
& Right Atrium  Measure E prime
 Acquire image with measurement
 4 Chamber Acquire cine loop tissue Doppler imaging (TDI) of right ventricle and 1/3 of the left
Right Ventricle atrium: Place pulsed Doppler cursor at the medial aspect of the TV annulus:
& Right Atrium  Measure E prime
 Acquire image with measurement

VI. Apical 5-Chamber View Overview

A. Capture 2D image.
B. Perform Color Doppler, PW and CW Doppler of LVOT; pay attention to the position of PW
sample volume.
C. Perform continuous wave Doppler for IVRT measurement

Apical Window 5 Chamber Scan Plane

Structure Image Stored

5 Chamber Acquire a continuous wave Doppler between the aortic and mitral valve leaflets:
LVOT & Aortic  Measure the IVRT
valve
5 LVOT & Acquire cine loop 2D image of left atrium, left ventricle, aorta, right atrium, & right
Aortic valve ventricle
Chamber

5 Chamber Acquire cine loop color Doppler across the aortic valve
LVOT & Aortic
valve
5 Chamber Acquire continuous wave Doppler across the aortic valve:
LVOT & Aortic  Measure peak velocity (If continuous wave Doppler gradient is over 2
valve m/sec trace the spectral envelope) IF AR is present, measure descending
slope
 Normal range is 1.0 – 1.7 m/s
 Acquire image with measurement
5 Chamber Acquire pulse wave Doppler of left ventricle outflow track:
LVOT & MV  Measure peak velocity of the left ventricle outflow track.
 Normal range is 0.7 - 1.1 m/s
 Acquire image with measurement

VII. Apical 2-Chamber View Overview

A. Capture 2D image, take care not to foreshorten the image.
B. Perform color Doppler of the MV.
C. Perform LA area and volume as needed.
VIII. Apical 3-Chamber View (Apical Long-Axis View) Overview
A. Capture 2D image, take care not to foreshorten the image.
B. Perform color Doppler of the MV and the AV.
C. Perform PW/CW of LVOT/AV (in presence or suspicion of aortic stenosis or calcification or
LVOT obstruction). Pay attention to the position of PW sample volume.
 Apical Window 4, 3, & 2 Chamber Scan Plane

Structure Image Stored

2 Chamber *Biplane Simpson’s Method:

LV, MV, LA  Acquire an apical 4 chamber image and freeze
 Scroll to end-diastole and trace the LV cavity and store image
 Measure the length of the LVED from the mid mitral annulus to the cardiac
apex and store image
 This will give you the LV ED volume DO NOT UNFREEZE THE IMAGE
 Scroll to end-systole and trace the LV cavity and store image
 Measure the length of the LVED from the mid mitral annulus to the cardiac
apex and store image
 This will give you the LV ES volume
2 Chamber Acquire cine loop of 2D image of the left atrium & left ventricle
LV, MV, LA
2 Chamber Acquire cine loop of color Doppler across the mitral valve
LV, MV, LA
2 Chamber Acquire a 2 chamber left heart image and freeze
LV, MV, LA  Trace LA volume in 2 chamber
 Acquire image with measurement
2 Chamber Acquire cine loop of 2D image decreasing depth to demonstrate the left ventricle &
LV and LA 1/3 of the left atrium
3 Chamber Acquire cine loop of 2D image of the left atrium, left ventricle, & aortic valve
LA, MV, LV, AV
3 Chamber Acquire cine loop of color Doppler across the mitral valve & aortic valve
LA, MV, LV, AV
3 Chamber Acquire cine loop of 2D image decreasing depth to demonstrate the left ventricle &
LA, MV, LV, AV 1/3 of the left atrium
4 Chamber Acquire cine loop of 2D image of 4 chamber demonstrating the left ventricle on the
Mayo View LEFT side of the SCREEN & the right ventricle on the RIGHT side of the SCREEN
(Mayo Clinic)

IX. Subcostal View Overview

A. Capture 2D image.
B. Perform color Doppler of the MV and TV and IAS and IVS to look for a shunt.
C. Perform CW for the TR velocity to calculate pressure gradient as needed.
D. Capture 2D of the IVC and observe for collapse (set for 3–5 seconds to appropriately capture).
Be sure to include inspiration/expiration and “sniff” if needed.
E. Perform color Doppler of HV/IVC.
F. Perform PW Doppler of the HV/IVC flow.
G. Capture 2D subcostal short-axis view as needed (if parasternal view is not optimal).

Subcostal Window Long Axis Scan Plane and Short Axis Scan Plane
 Structure Image Stored

4 Chamber LAX Acquire cine loop 2D image of 4 chambers

4 Chamber LAX Acquire cine loop color Doppler across the Interatrial septum (IAS) for shunts

4 Chamber LAX Acquire cine loop color Doppler across the interventicular septum for shunts

4 Chamber LAX Acquire cine loop color Doppler across the mitral valve & tricuspid valve

IVC LAX Acquire cine loop 2D image of inferior vena cava for collapse (change EKG to 5
beats)

IVC LAX Acquire cine loop 2D image of inferior vena cava for collapse (change EKG to 5
beats)
 Measure IVC
IVC LAX Acquire frozen M-mode image of inferior vena cava

IVC LAX Acquire frozen M-mode image of inferior vena cava with a sniff test

IVC & Hepatic Acquire cine loop Color Doppler image of inferior vena cava and hepatic veins for
veins SAX collapse (change EKG back to 2 beats)
Aorta LAX Acquire cine loop 2D image of the aorta

Aorta LAX Acquire cine loop color Doppler of the aorta

X. Suprasternal View Overview

A. Capture 2D image of aortic arch, upper and descending aorta as needed.
B. Perform color Doppler, PW and CW Doppler as needed.
Suprasternal Notch Window Long Axis Scan Plane

Structure Image Stored

Aortic arch and Acquire cine loop 2D image of the aortic arch and descending aorta
Descending
aorta
Aortic arch and Acquire cine loop color Doppler flow of the descending aorta
Descending
aorta
Aortic arch and Acquire pulsed wave Doppler through the descending aorta
Descending
aorta
Aortic arch and If PW Doppler was >200 cm/s, acquire continuous wave Doppler through the
Descending descending aorta
aorta

Appendix
In addition to the above protocol, we are responsible for obtaining additional images, measurements
and Doppler for aortic stenosis.
Aortic Stenosis or Suspected Aortic Stenosis
1. Measure LVOT at the parasternal long-axis view
2. “Zoom” on LVOT; adjust focal point and gain, to optimize measurement of LVOT diameter.
3. In the apical 5-chamber view, obtain PW aortic outflow with appropriate position of PW
sample volume, trace the best wave form.
4. In the apical 5-chamber view, obtain CW of aortic outflow
5. Dedicated non-imaging CW Doppler in multiple locations, at the Apex, Suprasternal Notch
and Right Parasternal Border (reposition patient onto right side position may be required) to
obtain maximal velocity.
6. Trace the best Doppler wave form for calculation of aortic valve area using Continuity
Equation
7. Pay attention to the size of LVOT, PW LVOT flow, ascending aorta and arch.
8. Obtain zoom and optimized view of the valve in the parasternal short axis view
Aortic Regurgitation
1. Pay attention to the morphology and mechanism of the aortic regurgitation (e.g. bicuspid,
flail, prolapse) including jet direction and origins
2. Pay attention to the size of the annulus, ascending aorta, arch and co-existing AS
assessment
3. Measure deceleration slope on continuous wave (CW) Doppler of AI from apical 4 or 3
chamber views as needed.
4. Imaging Suprasternal Notch (SSN) and perform pulsed Doppler of Descending Aorta Flow
distal to the Subclavian Artery to check for Diastolic Flow Reversal as needed
Prosthetic Aortic Valve
1. Type and size of prosthesis (from consult, note or patient card) should be entered into
report if information available.
2. Peak and mean gradients and CW velocities (from apical 5 chamber or apical long axis views
right sternal or suprasternal notch flow.) Average 3 the best beats for patient in A Fib as
needed.
Pulmonic Stenosis
1. Perform Pulse Doppler of the Pulmonic Flow in Parasternal Short Axis and RVOT
2. Use CW Doppler (Pedoff) at Left Parasternal Border
3. Calculate pressure gradient by tracing CW.
Mitral Stenosis
1. Pay attention to the morphology including subvalvular apparatus.
2. Trace CW of Mitral Valve Inflow for mean and peak pressure gradients (average of three
beats with A Fib).
3. Obtain deceleration slope of mitral CW at 100 mm/sec for measurement of pressure Half-
time).
4. In short axis, obtain optimized view at leaflet tips and trace mitral orifice for valve area
(native valve only) if possible
Mitral Regurgitation (more than mild)
1. Pay attention to the mechanisms of MR (chordal rupture; flail leaflet; myxomatous
degeneration; papillary muscle infarct; chordal thickening/rheumatic changes) including the
origin & jet direction
2. Demonstrate presence of Mitral Regurgitation with color Doppler, search for maximal color
mapping of regurgitation if eccentric mitral regurgitation is present in multiple views
 including off-axis view. If mitral regurgitation is more than moderate, consider calculation of
ERO by PISA method as needed.
3. “Zoom” of the Mitral Valve
4. Baseline shift of color Doppler to reduce aliasing velocity to approximately 30-40 cm / sec)
5. Measure aliasing radius from first blue / red aliasing interface to regurgitant orifice (PISA
shell) in the frozen color Doppler image
6. Obtain peak Mitral Regurgitant Velocity from CW of mitral regurgitation
7. Pulmonary venous flow obtained if possible with emphasis on systolic flow component
Prosthetic Mitral Valves
1. Type and size of prosthesis (from chart, op note or patient card)
2. Peak and mean gradient by CW
3. Calculation of MV area by Continuity Equation
4. Search for MR in multiple view
Pericardial Effusion
1. Look for RV collapse and RA collapse using 2D mode and M-mode in multiple views
(parasternal, apical and subcostal views)
2. M-mode through RV at mitral valve level in short axis- run at 100 cm/min speed
3. M-mode RV in the Parasternal Long Axis as needed
4. Pulse mitral and tricuspid inflow at 25-50 mm/min speed to look for changes with
inspiration and expiration
5. Perform 2D and Pulsed Doppler of the Hepatic Vein / the Inferior Vena Cava flow. Dilation of
hepatic venous flow indicates increase in RA pressure.
Hypertrophic Cardiomyopathy
1. Pay attention to LV thickness including maximal septal thickness, SAM and eccentric mitral
regurgitation caused by SAM.
2. Pulse along the LVOT to show acceleration (dagger shape) to elicit location of pressure
gradient if possible (sample volume should be placed at the site of obstruction, view frozen
and image acquired at each level of LV to actually show the exact site of the obstruction
3. Perform CW Doppler to obtain maximal intraventricular / LVOT pressure gradient
4. Localization of the LVOT gradient using PW, distinguish from intra-cavitary gradients
5. Spectral Doppler is performed in apical 4-, 5 and 3 chamber view to obtain the best image.
6. If LVOT velocity is > 3cm/sec, ask physician regarding provocative test- amyl nitrates
needed. ; Valsalva maneuver acceptable if patient can perform adequately.
Completion of Study
1. End study and transfer study PACS
If a sonographer detects any potential life-threatening abnormalities, notify the reading
physician and/or fellow immediately, do not allow patient to leave the lab.
2. If there are any questions about image quality, special views or procedures needed to
answer all clinical questions, notify the reading physician and/or fellow before a patient
leaves the lab.
3. Disconnect the patient and remove gel with wash cloth. Wipe the probe and machine down
with a disposable disinfectant cloth to disinfect
4. Place linen in laundry bag and change linens
5. Complete data entry
Tips
 Pharmaceutical Contrast
 May be utilized upon receiving a written order from the physician.
 Pharmaceutical contrast is indicated for use in patients with 2 or more suboptimal
segments of the left ventricular endocardial borders.
  Pharmaceutical contrast is contraindicated for patients with known or suspected:
 Cardiovascular or pulmonary compromise
 Hypersensitivity to perflutren (lipid micro gas), blood products or albumin (egg
white allergy)
 Technically difficult exams
 Document normal cardiac windows with limited views
 Utilize modified views to acquire diagnostic images for physician interpretation

Biplane Simpson’s Method of Discs: Uses the summation of the areas from the diameters of 20 cylinders
or discs of equal height is used to calculate the end- diastolic volume, end-systolic volume, stroke
volume, cardiac output, cardiac index, and ejection fraction.

Labs:
 Troponin: an elevated troponin may indicate a myocardial infarction
 BNP (Brain natriuretic peptide: an elevated BNP is an indication of the myocardial tissue being
stretched as in the case of CHF
Additional measurements that may be required per site’s protocol from the PLAX view.

Aortic Valve IF INDICATED: Measure the following on the aortic valve M-mode:
PLAX M-mode  Aortic root end-diastolic dimension
measurements  Measure the vertical distance from the outer edge of the anterior aortic
root to the inner edge (leading edge to leading edge) of the posterior
aortic wall at end-diastole.
 Normal range 2.0-3.7 cm
 LA end-systolic dimension
 Measure greatest vertical distance between the posterior aortic wall
and the posterior left atrial wall inner edge to inner edge (AKA: trailing
edge to leading edge) at end ventricular systole when the aorta is in its
maximal anterior position.
 Normal range 1.9-4.0cm
 Aortic valve systolic separation
 Measure the maximal opening of the aortic valve cusps during the initial
part of ventricular systole, using the internal borders of the aortic cusps.
 Normal range 1.5-2.6 cm
Mitral Valve IF INDICATED Measure the following with the mitral valve M-mode:
PLAX M-mode  E-F slope
measurements  Measure the distance of the steepest initial portion of the anterior MV
leaflet by placing a caliper on the steepest point of early diastole and
then place a caliper at the end of the slope.
 Normal range is 70-150 mm/s.
 E Point Septal Separation (EPSS)
 Measure the vertical distance from the MV E point to the lowest point
of the IVS.
 Normal range is 2-7 mm.
 Left Ventricle IF INDICATED Measure the following with the left ventricle M-mode:
PLAX M-mode  Interventricular Septum in diastole (IVSd)
measurements  Measure the diastolic thickness of the IVS as the vertical distance from
the RV side of the IVS to the LV side of the IVS in end-diastole at a point
corresponding to the onset of the QRS complex.
 Normal range 0.6-1.1 cm
 Left Ventricle Inner diameter in diastole (LVIDd)
 Measure the vertical distance from the endocardium of the IVS to the
endocardium of the PWLV in end-diastole at a point corresponding to
the onset of the QRS complex.
 Normal range 3.7 – 5.6 cm
 Left Ventricle Posterior Wall in diastole (LVPWd)
 Measure the vertical distance from the endocardium of the LVPW to the
epicardium in end-diastole at a point corresponding to the onset of the
QRS complex.
 Normal range 0.6 – 1.1 cm
 Interventricular Septum in systole (IVSs)
 Measure the systolic thickness of the IVS as the maximal vertical
distance that occurs between the RV and LV sides of the IVS at
ventricular systole
 Left Ventricle Inner Diameter in systole (LVIDs)
 Measure the vertical distance from the endocardium of the IVS at the
lowest point of the septal motion to the endocardium of the LVPW in
end-systole.
 Normal range 2.0 – 3.8 cm
 Left Ventricle Posterior Wall in systole (LVPWs)
 Measure the systolic thickness of the LVPW at the maximal vertical
distance that occurs between the endocardium and epicardium at end-
ventricular systole
Right Ventricle Freeze 2D image of left ventricle without papillary muscles and AV closure in the center
PLAX 2D of the aorta, both aortic and mitral valve in the maximal excursion:
measurements Scroll back to end diastole (mitral valve closure or QRS) and measure the following:
 *Right Ventricular Minor Axis in diastole (RVIDd)
 Measure the inner edge to inner edge dimension is measured at the
same level as the LV minor axis dimensions parallel to this
measurement.
 Normal range is 1.9-3.8 cm
RVOT from Right ventricular outflow track (RVOT)
PLAX Acquire cine loop of 2D image of right ventricular outflow track (RVOT)
RVOT from Acquire cine loop of color Doppler across the pulmonary valve (PV)
PLAX
RVOT from Acquire continuous wave Doppler across the pulmonary valve IF pulmonary
PLAX regurgitation present

V. Right Parasternal View

A. Capture 2D image of the ascending aorta as needed, especially if aortic dissection & aneurysm
are suspected.
 B. Perform color Doppler and CW Doppler as needed for aortic stenosis.

Additional off-axis 2D image/color Doppler imaging may be performed as needed to supplement

standard views (eccentric mitral regurgitation, congenital heart disease, etc.).