Adult Echo - Modules 2 & 3

Name the 4 standard windows.

• parasternal

• apical

• subcostal

• suprasternal

Name the 4 standard planes.

• long axis

• short axis

• four chamber

• two chamber

Describe why correct positioning of the image plane is important. i.e. being on-axis

• determines the reliability of dimensions

• appreciate the motion

• reproducibility of the study

List the 7 standard views within the parasternal window.

• PSLAX

• RVIT

• RVOT

• PSSAX at AoV

• PSSAX at MV

• PSSAX at papillary muscles

• PSSAX at apex

Draw and label the PSLAX.

Draw and label the RVIT in parasternal window.

Draw and label the RVOT in parasternal window.

Draw and label the PSSAX at the AoV.

Draw and label the PSSAX at the MV.

Draw and label the PSSAX at the papillary muscles.

Draw and label the apical 4 chamber view.

Draw and label the apical 5 chamber view.

Draw and label the apical 2 chamber view.

Draw and label the apical 3 chamber view.

Draw and label the subcostal 4 chamber view.

Draw and label subcostal short axis at IVC.

Draw and label the suprasternal notch view.

Outline how to optimize the standard Parasternal echo views.

• Correct alignment of the transducer on axis

• Center the anatomy

• Instrumentation settings (gain, focus, depth, etc.)

Label the LV wall segments in short axis and which axis cuts through opposite segments.

List the perfusion of the RV wall segments.

• RCA - posterior descending artery

• RCA - acute marginal artery

• RCA - conus branch

• LAD

List the RV wall segments

• anterior

• inferior

• lateral

• infundibular (RVOT)

• IVS

Describe the moderator band and it’s function

Located at the RV apex to propagate AP from the right bundle branch to the anterolateral RV wall

Describe the costal position of each acoustic window.

Parasternal - 2nd-4th intercostal space

Apical - 5th-6th intercostal space

Subcostal - interior to sternum

Suprasternal - superior to sternum

In the subcostal window, the patient is positioned…

Supine with knees bent and stomach relaxed

In a subcostal 4 chamber, the aorta is in view. How would you fix this plane?

Angle the transducer posteriorly.

Transducer is angled too anteriorly if the aorta is in view.

What is an advantage of subcostal 4-chamber over apical 4-chamber?

Optimal for assessing integrity of the IAS and IVS because the sound beam is perpendicular.

Optimal for visualizing pericardial effusion.

What structures tend to drop out in apical 4-chamber and why?

IAS and IVS - these structures are parallel to the sound beam in apical window.

What is imaged though tilting the transducer in subcostal short axis? Sketch an image.

• IVC/hepatic vein

• RA

• TV

From what window and plane is the abdominal aorta in long axis visible?

Subcostal short axis at the level of the MV/papillary muscles, tilt inferior

Draw the subcostal SAX at the abdominal Ao.

Describe the Sniff test and its purpose.

Ask the patient to sniff to collapse the IVC

Measure the diameter of the IVC and its collapsibility index to assess RA pressure

Name the 3 views in subcostal SAX and describe the maneuvers to reach those views.

IVC, Hepatic veins

• indicator towards pt head

• angles right to the posterior aspect of the heart

AV, MV, pap muscles, apex

• tilt superior from IVC view

Abdominal Ao

• angle the td leftward from IVC view

• rotate to elongate abdominal Ao

Describe patient position when imaging the suprasternal window.

Patient laying supine with neck extended

Describe the transducer maneuvers to image the suprasternal notch.

• indicator points to pt left ear

• angle the transducer leftward until the arch appears

• rotate to elongate

Explain the purpose of using M-mode.

• precise recording of the position and motion of cardiac muscle, valves, and surrounding tissue

• measurements can be compared against normal values

What is represented in the x and y axis of M-mode

x axis - time

y axis - depth

Name the primary limitation of M-mode.

If the M-mode line is not perpendicular with the anatomy, the measurement will be inaccurate

In an M-mode tracing of LV basal wall in PSLAX, list the measurements made and describe how to measure them

AoV

• curser where the AoV leaflets close in diastole

• aortic root diameter measured at end diastole from the tissue interface of the anterior wall of aortic root to posterior wall of aortic root

• LA measured at end systole from the trailing tissue interface to posterior tissue interface

MV

• cursor at the mitral valve leaflet tips

• E point septal separation - space between the anterior leaflet and anterior LA wall

LV basal wall

• cursor just past the mitral valve leaflets

• IVS measured at end diastole from the right to left surfaces of the IVS

• LVIDd measured at end diastole from the tissue edge of anteroseptal interface to tissue edge of inferolateral interface

• Inferolateral wall diameter measured in end diastole from the endocardial surface to epicardial surface of the posterior wall

• LVIDs measured at end systole from the tissue edge of anteroseptal interface to tissue edge of inferolateral interface

Normal value for LVIDd

W: 3.8 - 5.2cm

M: 4.2 - 5.8cm

Normal value for LVIDs

W: 2.2 - 3.5cm

M: 2.5 - 4.0cm

Normal value for IVS wall thickness

W: 0.6 - 0.9 cm

M: 0.6 - 1.0 cm

Normal value for posterior wall thickness

W: 0.6 - 0.9 cm

M: 0.6 - 1.0 cm

Normal range for aortic root

2.2 - 3.6 cm

Normal range for LA diameter

W: 2.7 - 3.8 cm

M: 3.0 - 4.0

What could cause a high EPSS (>5mm)?

• dilated LV

• mitral stenosis

• aortic regurgitation

Define TAPSE

Tricuspid annular plane systolic excursion

• from RV focused view

• TAPSE<16mm = RV dysfunction

How much does the IVC collapse during the sniff test with a healthy RA? What is expected with an unhealthy RA?

Healthy - collapse more than 50%

Unhealthy - collapse less than 50%

Why measure echocardiograms?

• echo exams can be standardized

  • study reproducibility

• distances can be measures accurately

• provides important diagnostic information

  • compare to normal values

• important for follow ups (progress)

List the phases of an ECG.

1. atrial systole

2. isovolumetric contraction time

3. rapid ejection 

4. reduced ejection

5. isovolumetric relaxation time

6. rapid filling

7. reduced filling

Name the two methods for calculating LV volumes from LV linear dimensions. Why are these not recommended for clinical use?

Teichholtz Method

Guinones Prolate Ellipsoid Method

Both rely on the assumption that the LV is a fixed geometric shape (prolate ellipse) - inaccurate assumption for many cardiac pathologies

Normal range for LV EF%

W: 54 - 74%

M: 52 - 72%

Normal range for FS

25 - 45%

A female patient has an EF of 45%. Is this normal? If no, what should the sonographer be looking for?

45% is lower than the normal range of 54-74%

This can be indictive of hypokinetic walls due to decreased contractility.

A female patient has an EF of 58%. Is this normal? If no, what should the sonographer be looking for?

58% falls within the normal range for a female.

When are 2D measurements used?

When M-mode is not optimal due to structures oblique to the cursor

What are some limitations of 2D measurements?

Lack of temporal resolution - may not get the optimal frame for measuring

Subject to more sonographer variability

Name the measurements made in PSLAX and when they are made.

End-diastole:

• Ao root

• IVS diameter

• LVIDd

• PW diameter

End-systole:

• LA diameter

• LVIDs

What are mechanical and electrical indicators of end systole?

Mechanical: frame after aortic closure, LV is smallest

Electrical: end of T-wave

What are the mechanical and electrical indicators of end diastole?

Mechanical: frame after MV closure

Electrical: peak R-wave

Where are measurements for the right heart imaged from?

Apical 4 chamber

The LA used to be measured from the PSLAX anterior-posterior walls. Why is this no longer standard?

The relationship between the LA dimensions and the AP dimension is not maintained as the LA enlarges - inaccurate prediction of LA volume

Describe how the LA is measured.

In apical 4 chamber at end systole using an biplane area-length calculation

What is the difference between LAV and LAVI?

LAVI is the LAV indexed to body mass to make the measurement more diagnostic