Apical 4C Testout Protocol / knowing the different waveforms

1 step

Obtain and hold apical 4 chamber view

Step 2

Obtain zoomed LA view 2D

Step 3

Obtain Pulmonary veins with color (optimization 2-5 sample volume)

Step 4

Obtain PW of pulmonary veins

Step 5

Demonstrate CFI over MV to the LA and over IAS for MR

MR?

Step 6

correctly obtain CW doppler for MS (scale at 6) show above the baseline (compression at 12)

Step 7

Obtain a PW doppler for MV inflow

Step 8

Obtain a septal TDI (w/proper sample volume gate) gate 5-10mm

step 9

Obtain a Lateral TDI (w/proper sample volume gate) gate 5-10mm

Step 10

Zoom on AV and demonstrate 2D+ color in A5C

Step 11

Perform, CW doppler through AV for stenosis

step 12

perform CW doppler through AV regurgitation

step 13

perform LVOT PW doppler for SV with proper gate size (2-5)

step 14

performs CW between AV and AMVL for IVRT

step 15

obtain a IVS with color

step 16

Obtain an on axis images for the right heart

step 17

obtain an on axis RV focused view

step 18

Perform a TAPSE mmode at the TV annulus

step 19

Perform S’ TDI doppler at the TV annulus

Step 20

Zoom 2D + CF on the RA (Color should color the valve to the roof)

step 21

Perform a CW for TR

Step 22

obtain a parapical view 2D, color, and doppler for TR

step 23

Obtain a “mayo” view 2D, color, and doppler for TR

Step 24

obtain, hold, and image an apex shot in A4C

MEASUREMENTS

Correctly measure LA area and length in A4C

step 1

Correctly measure LA area and length in A4C

step 2

Correctly measure a CW doppler for MS

step 3

correctly measure a PW doppler for Mitral inflow (E wave, A wave, and decel time)

step 4

correctly measure septal and lateral TDI (e’ and a’)

step 5

correctly measure and Ar-A wave duration

step 6

correctly measure IVRT (AVO-MVC)

step 7

correctly measure a PW LVOT TVI for SV

step 8

measure a CW AV VTI for AS

Step 9

measure a TAPSE and S’ TDI

Step 10

If full TR envelope is present, measure the peak velocity

step 11

Correctly measure RA area and length at end-systole

Step 12

Correctly measure a RV (Base, mid and length)

Step 13

Correctly measure a RV end diastolic for FAC% (area)

step 14

Correctly measure RV end systolic for FAC% (area)

what measure measurement is this, explain how would want to measure this and what View,

Measured the LA area and length in A4C, at its largest dimension before the leaflet tips (MV) open at end-systole, want to exclude the Pulmonary vein and mitral annulus, this is when you need to trace the chamber and length. the normal LA area is going to be less than or equal to 20 or 24? (THIS IS NOT OUT LAV INDEX)

when we do our color flow what are we looing for the step we look at the pulmonary vein with color?

So, we look at the color of the pulmonary veins and for any MR, the normal flow pulmonary vein to LA to MV and the to LV, so any blue flow is going to be that MR reaching back and this red flow will be the pulmonary vein

what single is this measurement for what are you going to peak, why would this doppler be important

this measure is for the pulmonary vein

Pulmonary vein peak systolic velocity (peak the S wave)

Peak D wave

peak the velocity of the atrial reversal or atrial duration

This will important when interrogate for MR, If the S wave is shorter than ourt D that is blunting so this coulf point to moderate or severe regurgitation if you see a reversal in these two

what measurement would this be

trace this measure when you get a really nice envelope, this is she MVR PISA method and measure MVR VTI (the jet is u-shaped)

what is this measurement for

This measuring above the baseline for stenosis, this is our MV VTI

you want to Trace the E and A, a normal MV mean gradient is going to be less than five (if we see a very heavy calcified vale that is not opening well the CW is going to assessing for)

what measurement is this showing

PW doppler will be for diastology, placing the gate at the MV Leaflet tips and we have our E and A wave and will peak them and the MV decel time

The E wave is showing the early rapid LV fiiling it usally sits around the end of the T wave and then in early diastole

The A wave is our late LV filling an atrial contraction this will be right before our r wave

what is this measurement for

Septal side

measure the MV septal E

and then MV septal A velocity

gate should be 5-10

what measurement is this for

Lateral side

Peak lateral e’ and a’

what measurement is this

Strove volume measurement

PW signal of the LVOT VTI

this will be a trace, trace the oustide

what measurement is this

now for assessing for stenosis AV VTI using CW

this will be a trace

what measurement is this for

RA volume, measure when the chamber is at its largest, just right before the TV open, at end-systole

Trace the chamber excluding the TV annulus

and we also do a length

a normal RA size is going to be less than 19 centimeters squared

what is this measurement for

RV focused view this will be a lateral tilt

do a base, mid, and length measure along with the fractional area of change measurement (FAC%)

measure at the end of the QRS / end-diastole

RV diastolic area, trace it

when doing the base measurement do not bring it down past the annulus you will be right at the base of the actual ventricle

mid length, in the middle of the ventricle

and then perform the diastolic length, so RV apex all the way down

the area and the diastolic area and the systolic area give us fractional area of change this is showing our radio function, how the msucle is moving inwards that is our radial function that is our FAC %

what measurement is this

this will be for FAC% but of the RV but at end-systole you want it at the smallest dimension but before the leaflets pop open

this will be for our RV systolic area, make sure when you trace bringing it all the way up to the RV apex this will be RV systolic area

what is the TAPSE and S’ measurements

TAPSE and S’ is the longitudinal function measure how well the muscle is moving up and down

our TAPSE and S’ should match normal numbers b/c they are measuring the same thing so it should match normal

what is the measurement for

this is going to be the RV systolic function, this is the TAPSE measurement from the bottom of the hill to the top of the hill the normal values for TAPSE is >1.7- <2.4

what is the measuring

This is our S’, should be >9.5

what measurement is this for

TR, peak the TR

what measurement is this for

IVRT, perform CW between aortic valve and AMVL for IVRT (measure AVC-MVO)

what is the normal mitral inflow waveform look like and the pulmonary vein flow and TDI look like what’s its e’ and E/A ratio?

what does the impaired mitral inflow waveform look like and the pulmonary vein flow and TDI look like what’s its e’ and E/A ratio?

what does the pseudonormal mitral inflow waveform look like and the pulmonary vein flow and TDI look like what’s its e’ and E/A ratio?

what does the restrictive mitral inflow waveform look like and the pulmonary vein flow and TDI look like what’s its e’ and E/A ratio?