echo interpretation · tricuspid stenosis mean pressure gradient (mm hg) ≥ 5. mitral inflow...

Echo InterpretationJason R. Morrissette, MSHS, MBA-HCM, PA-C

Echo Machine

Transthoracic Echocardiography Windows

• Left parasternal• Long axis view

• Short axis view

• Apical window• 4 chamber view

• 5 chamber view

• 3 chamber view

• 2 chamber view

• Subcostal/Subxiphoid window• Interatrial septum

• IVC

• Suprasternal window

Parasternal Window, Long Axis

Parasternal Window, Short Axis

Parasternal window, short axis

Apical window, 4 Chamber

Apical window, 5 Chamber

Apical window, 2 Chamber Apical window, 3 Chamber

Subxiphoid View

Suprasternal View

Chamber Evaluation

• Left ventricle size and function

• Left ventricle wall thickness

• Left atrium dimensions

• Right ventricular size and shape

Left Ventricle Size

• Measure in parasternal long axis, at the tip of the mitral leaflets

• Diastolic diameter: End diastole, frame after mitral closure; largest cardiac dimension

• Systolic diameter: End systole, frame preceding mitral valve opening; smallest cardiac dimension

• Exclude chordae and papillary muscle from measurement

• Measure perpendicularly to long axis of LV

• LV apex should not be visualized

Left Ventricle Size

Diastolic Diameter of LV

Systolic Diameter of LV

M-Mode of LV

Left Ventricular Thickness

• Measure in parasternal long axis at end-diastole

• Exclude chordae and papillary muscle

• Exclude moderate bands from right ventricle

NormalMildly

abnormalModerately abnormal

Severely abnormal

LV Thickness (cm) 0.6 - 0.9 1.0 - 1.2 1.3 - 1.5 ≥1.6

Left Ventricular Thickness

Left Atrial Size

• Measured at end systole where LA chamber is at its greatest dimension

• Parasternal long axis, perpendicularly to the LA walls, leading edge to leading edge

Women MenAP Dimension (cm) 2.7 - 3.8 3.0 - 4.0

Left Atrial Size

Left Atrial Size - Volume

4 Chamber 2 Chamber

Right Ventricle Size

Right Ventricle Size

Normal Mildly abnormalModerately abnormal

Severely abnormal

RV ED Diameter (cm) 2.7 - 3.3 3.4 - 3.7 3.8 - 4.1 ≥4.2

Normal: RV < LV

Mildly enlarged: RV < LV

Moderately enlarged: RV = LV

Severely enlarged: RV > LV

Right Ventricle Shape• Normal: Crescent

• Pressure/Volume overload: End-diastolic pressure of RV exceeds LV causing flatness of septum and inward bowing of LV during end-diastole and then in systole

RV

LV

IVC assessment

• Subcostal 4 chamber view

• Visualize IVC merging with right atrium

• Measure 2-3 cm before merging with RA, parallel walls

• M mode across IVC

IVC Abdominal Aorta

Direction Goes through liver Goes through liver

Relationship to heart Merges with RA Continues down the heart

Flow Continuous Pulsatile

Walls Not visible Hyperechoic

Respiratory variation Yes No

Collateral vessels Hepatic veins merge with IVC Not visible at this level

IVC and Aorta

IVC and Aorta

IVC Aorta

Left Ventricular Segmentation

Ejection Fraction

•Normal 52 – 72%

•Mildly reduced 41 - 51%

•Moderately reduced 30 – 40%

• Severely reduced < 30%

EF – Normal (52-72%)

EF-Mildly Reduced (41-51%)

EF-Moderately Reduced (30-40%)

EF-Severely Reduced (<30%)

Regional Wall Motion Abnormalities

• Septal hypokinesis

• Inferior and inferolateral hypokinesis

• Left and Right Ventricle dysfunction

Septal hypokinesis

Inferior and inferolateral hypokinesis

Left and Right Ventricle Dysfunction

Pericardial Effusion

Pericardial Effusion

Tamponade

• Early signs• IVC dilated, not collapsing • Increased respiratory variation in

mitral (> 25%) and tricuspid (> 40%) inflows

• Late signs• RA/RV collapse

• Very late signs• LA/LV collapse

Valve pathology

• Mitral regurgitation

• Mitral stenosis

• Aortic insufficiency

• Aortic stenosis

• Tricuspid regurgitation

• Tricuspid stenosis

Mitral Regurgitation

Jet area–Color Flow• Simple, quick screen for mild or severe central MR;

evaluates spatial orientation of jet

• Subject to technical, hemodynamic variation; significantly underestimates severity in wall-impinging (eccentric) jets

Mitral Regurgitation

Mitral Regurgitation: Torn MV Chord

Mitral Stenosis

Mild Moderate Severe

Valve Area (cm2) > 1.5 1.0 - 1.5 < 1.0

Mean gradient (mmHg) < 5 5.0 - 10 > 10

Aortic Insufficiency

Jet width in LVOT–Color Flow• Mild• Moderate • Severe

Jet deceleration rate – Pressure ½ time (msec)• Mild severity: > 500 • Moderate severity: 500-200 • Severe severity < 200

Aortic Insufficiency

Aortic Insufficiency – Pressure ½ time

Aortic Stenosis

• (LVOT) velocity: measured from the apical approach either in an apical long-axis view or an anteriorly angulated four-chamber view

• Left ventricular outflow tract (LVOT) diameter- measured in the parasternal long-axis view in mid-systole

• Aortic valve jet velocity

Aortic Stenosis: Grading Severity

Aortic Stenosis

Aortic Stenosis: Pre surg

Aortic Stenosis: Post surg

Systolic anterior motion (SAM) of MV

•Apposition of the tip of the mitral leaflet and septum in mid to late systole

• Subaortic obstruction in hypertrophic cardiomyopathy

SAM

SAM

Tricuspid Regurgitation

Jet area–Color flow

• Simple, quick screen for TR

• Underestimates severity in eccentric jets

Pulmonary Artery Pressure

• MPAP systole = 4 * (TR jet velocity)2 + Right Atrial Pressure (RAP)

RAP IVC diameter IVC collapsibility

3 mmHg < 21 mm >50%

8 mmHg < 21 mm <50%

10 mmHg > 21 mm >50%

15 mmHg > 21 mm <50%

Tricuspid Stenosis

Mean pressure gradient (mm Hg) ≥ 5

Mitral Inflow patterns

• Flow from Left Atrium to Left Ventricle occurs in 3 phases:

• E wave: Initial rush of blood into LV as MV opens in early diastole

• Diastasis: Period of low or no flow

• A wave: Atrial contraction results in final rush of blood into LV in end-diastole

Mitral inflow, diastolic dysfunction

Diastolic dysfunction

Normal Severe dysfunction

Myxoma

Right Atrial Mass

Bubble Study

Bubble Study - PFO

Left Ventricle Apical Thrombus

American Society of Echocardiography

• http://asecho.org